I 

115TH CONGRESS 

2D SESSION H. R. 5942 

To improve the health of minority individuals, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 23, 2018 

Ms. LEE (for herself, Mr. AGUILAR, Ms. BARRAGA ́N, Ms. BASS, Ms. 

BONAMICI, Ms. BORDALLO, Mr. BROWN of Maryland, Mr. CARBAJAL, 

Mr. CA ́RDENAS, Mr. CARSON of Indiana, Mr. CASTRO of Texas, Ms. 

JUDY CHU of California, Ms. CLARKE of New York, Mr. CORREA, Mr. 

DANNY K. DAVIS of Illinois, Mr. ELLISON, Ms. ESHOO, Mr. ESPAILLAT, 

Ms. FUDGE, Mr. GALLEGO, Mr. GOMEZ, Mr. AL GREEN of Texas, Mr. 

GRIJALVA, Mr. GUTIE ́RREZ, Ms. HANABUSA, Mr. HASTINGS, Ms. 

JAYAPAL, Ms. EDDIE BERNICE JOHNSON of Texas, Ms. KELLY of Illinois, Mr. KHANNA, Mr. LEWIS of Georgia, Mr. TED LIEU of California, 

Ms. LOFGREN, Mr. LOWENTHAL, Ms. MICHELLE LUJAN GRISHAM of 

New Mexico, Ms. MATSUI, Mr. MEEKS, Ms. MENG, Mrs. NAPOLITANO, 

Ms. NORTON, Mr. PAYNE, Mr. RASKIN, Mr. RICHMOND, Ms. ROYBALALLARD, Mr. RUSH, Mr. SABLAN, Ms. SA ́NCHEZ, Mr. SCHIFF, Mr. 

SCOTT of Virginia, Mr. SERRANO, Ms. SEWELL of Alabama, Mr. 

SWALWELL of California, Mr. TAKANO, Mrs. TORRES, Ms. VELA ́ZQUEZ, 

Ms. WILSON of Florida, Mrs. WATSON COLEMAN, and Mr. 

KRISHNAMOORTHI) introduced the following bill; which was referred to 

the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Agriculture, Education and the Workforce, the 

Budget, the Judiciary, Veterans’ Affairs, Armed Services, and Natural 

Resources, 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 improve the health of minority individuals, and for other 

purposes. 


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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 ‘‘Health Equity and 

5 Accountability Act of 2018’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents of this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

Sec. 3. Findings. 

TITLE I—DATA COLLECTION AND REPORTING 

Sec. 101. Amendment to the Public Health Service Act. 

Sec. 102. Elimination of prerequisite of direct appropriations for data collection 

and analysis. 

Sec. 103. Collection of race and ethnicity data by the Social Security Administration. 

Sec. 104. Revision of HIPAA claims standards. 

Sec. 105. National Center for Health Statistics. 

Sec. 106. Disparities data collected by the Federal Government. 

Sec. 107. Data collection and analysis grants to minority-serving institutions. 

Sec. 108. Standards for measuring sexual orientation and gender identity in 

collection of health data. 

Sec. 109. Standards for measuring socioeconomic status in collection of health 

data. 

Sec. 110. Safety and effectiveness of drugs with respect to racial and ethnic 

background. 

Sec. 111. Improving health data regarding Native Hawaiians and other Pacific 

Islanders. 

Sec. 112. Clarification of simplified administrative reporting requirement. 

TITLE II—CULTURALLY AND LINGUISTICALLY APPROPRIATE 

HEALTH AND HEALTH CARE 

Sec. 201. Definitions. 

Sec. 202. Amendment to the Public Health Service Act. 

Sec. 203. Pilot program for improvement and development of State medical interpreting services. 

Sec. 204. Training tomorrow’s doctors for culturally and linguistically appropriate care: graduate medical education. 

Sec. 205. Federal reimbursement for culturally and linguistically appropriate 

services under the Medicare, Medicaid, and State Children’s 

Health Insurance Programs. 

Sec. 206. Increasing understanding of and improving health literacy. 

Sec. 207. Assurances for receiving Federal funds. 

Sec. 208. Report on Federal efforts to provide culturally and linguistically appropriate health care services. 


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Sec. 209. English for speakers of other languages. 

Sec. 210. Implementation. 

Sec. 211. Language access services. 

TITLE III—HEALTH WORKFORCE DIVERSITY 

Sec. 301. Amendment to the Public Health Service Act. 

Sec. 302. Hispanic-serving health professions schools. 

Sec. 303. Loan repayment program of Centers for Disease Control and Prevention. 

Sec. 304. Cooperative agreements for online degree programs at schools of public health and schools of allied health. 

Sec. 305. Sense of Congress on the mission of the National Health Care Workforce Commission. 

Sec. 306. Scholarship and fellowship programs. 

Sec. 307. McNair Postbaccalaureate Achievement Program. 

Sec. 308. Rules for determination of full-time equivalent residents for cost-reporting periods. 

Sec. 309. Developing and implementing strategies for local health equity. 

Sec. 310. Loan forgiveness for mental and behavioral health social workers. 

Sec. 311. Health Professions Workforce Fund. 

Sec. 312. Findings; sense of Congress relating to graduate medical education. 

Sec. 313. Career support for skilled, internationally educated health professionals. 

TITLE IV—IMPROVING HEALTH CARE ACCESS AND QUALITY 

Subtitle A—Expansion of Coverage 

Sec. 401. Amendment to the Public Health Service Act. 

Sec. 402. Removing citizenship and immigration barriers to access to affordable 

health care under ACA. 

Sec. 403. Study on the uninsured. 

Sec. 404. Medicaid in the territories. 

Sec. 405. Extension of Medicare secondary payer. 

Sec. 406. Border health grants. 

Sec. 407. Removing Medicare barrier to health care. 

Sec. 408. 100 percent FMAP for medical assistance provided by urban Indian 

health centers. 

Sec. 409. 100 percent FMAP for medical assistance provided to a Native Hawaiian through a federally qualified health center or a Native 

Hawaiian health care system under the Medicaid program. 

Subtitle B—Expansion of Access 

Sec. 410. Protecting sensitive locations. 

Sec. 411. Grants for racial and ethnic approaches to community health. 

Sec. 412. Critical access hospital improvements. 

Sec. 413. Establishment of Rural Community Hospital (RCH) Program. 

Sec. 414. Medicare remote monitoring pilot projects. 

Sec. 415. Rural health quality advisory commission and demonstration projects. 

Sec. 416. Rural health care services. 

Sec. 417. Community health center collaborative access expansion. 

Sec. 418. Facilitating the provision of telehealth services across State lines. 

Sec. 419. Scoring of preventive health savings. 

Sec. 420. Sense of Congress on Maintenance of Effort Provisions Regarding 

Children’s Health. 


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Sec. 421. Repeal of requirement for documentation evidencing citizenship or 

nationality under the Medicaid program. 

Sec. 422. Protection of the HHS Offices of Minority Health. 

Sec. 423. Office of Minority Health in Veterans Health Administration of Department of Veterans Affairs. 

Sec. 424. Indian defined in PPACA. 

Sec. 425. Study of DSH payments to ensure hospital access for low-income patients. 

Sec. 426. Assistant Secretary of the Indian Health Service. 

Sec. 427. Reauthorization of the Native Hawaiian Health Care Improvement 

Act. 

Sec. 428. Availability of non-English language speaking providers. 

Sec. 429. Access to essential community providers. 

Sec. 430. Provider network adequacy in communities of color. 

Sec. 431. Improving access to dental care. 

Subtitle C—Advancing Health Equity Through Payment and Delivery Reform 

Sec. 441. Sense of Congress. 

Sec. 442. Centers for Medicare & Medicaid Services quality payment program. 

Sec. 443. Development and testing of disparity reducing delivery and payment 

models. 

Sec. 444. Supporting safety net and community-based providers to compete in 

value-based payment systems. 

Subtitle D—Health Empowerment Zones 

Sec. 451. Short title. 

Sec. 452. Findings. 

Sec. 453. Designation of health empowerment zones. 

Sec. 454. Assistance to those seeking designation. 

Sec. 455. Benefits of designation. 

Sec. 456. Definition. 

Sec. 457. Authorization of appropriations. 

Subtitle E—At-Risk Community Coverage 

Sec. 461. Medicaid coverage for citizens of Freely Associated States. 

Sec. 462. At-risk youth Medicaid protection. 

TITLE V—IMPROVING HEALTH OUTCOMES FOR WOMEN, 

CHILDREN, AND FAMILIES 

Subtitle A—In General 

Sec. 501. Grants to promote health for underserved communities. 

Sec. 502. Removing barriers to health care and nutrition assistance for children, pregnant persons, and lawfully present individuals. 

Sec. 503. Repeal of denial of benefits. 

Sec. 504. Birth defects prevention, risk reduction, and awareness. 

Sec. 505. Preventing maternal deaths. 

Sec. 506. Eliminating disparities in maternity health outcomes. 

Sec. 507. Decreasing the risk factors for sudden unexpected infant death and 

sudden unexplained death in childhood. 

Sec. 508. Reducing unintended teenage pregnancies. 

Sec. 509. Gestational diabetes. 

Sec. 510. Emergency contraception education and information programs. 


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Sec. 511. Comprehensive sex education programs. 

Sec. 512. Compassionate assistance for rape emergencies. 

Sec. 513. Access to birth control duties of pharmacies to ensure provision of 

FDA-approved contraception. 

Sec. 514. Additional focus area for the Office on Women’s Health. 

Sec. 515. Interagency coordinating committee on the promotion of optimal maternity outcomes. 

Sec. 516. Consumer education campaign. 

Sec. 517. Bibliographic database of systematic reviews for care of childbearing 

individuals and newborns. 

Sec. 518. Maternity care health professional shortage areas. 

Sec. 519. Expansion of CDC prevention research centers program to include 

centers on optimal maternity outcomes. 

Sec. 520. Expanding models allowed to be tested by Center for Medicare & 

Medicaid Innovation to include maternity care models. 

Sec. 521. Development of interprofessional maternity care educational models 

and tools. 

Sec. 522. Including within inpatient hospital services under Medicare services 

furnished by certain students, interns, and residents supervised 

by certified nurse midwives. 

Sec. 523. Grants to professional organizations to increase diversity in maternal, 

reproductive, and sexual health professionals. 

Sec. 524. Interagency update to the quality family planning guidelines. 

Sec. 525. Dissemination of the quality family planning guidelines. 

Subtitle B—Pregnancy Screening 

Sec. 531. Pregnancy intention screening initiative demonstration program. 

TITLE VI—MENTAL HEALTH 

Sec. 601. Mental health findings. 

Sec. 602. Coverage of marriage and family therapist services, mental health 

counselor services, and substance abuse counselor services 

under part B of the Medicare program. 

Sec. 603. Integrated Health Care Demonstration Program. 

Sec. 604. Addressing racial and ethnic minority mental health disparities research gaps. 

Sec. 605. Health professions competencies to address racial and ethnic minority 

mental health disparities. 

Sec. 606. Asian American, Native Hawaiian, and Pacific Islander behavioral 

and mental health outreach and education strategies. 

Sec. 607. Mental health in schools. 

Sec. 608. Geo-access study. 

TITLE VII—ADDRESSING HIGH IMPACT MINORITY DISEASES 

Subtitle A—Cancer 

Sec. 701. Lung cancer mortality reduction. 

Sec. 702. Expanding prostate cancer research, outreach, screening, testing, access, and treatment effectiveness. 

Sec. 703. Improved Medicaid coverage for certain breast and cervical cancer patients in the territories. 

Sec. 704. Cancer prevention and treatment demonstration for ethnic and racial 

minorities. 

Sec. 705. Reducing cancer disparities within Medicare. 


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Subtitle B—Viral Hepatitis and Liver Cancer Control and Prevention 

Sec. 711. Viral hepatitis and liver cancer control and prevention. 

Subtitle C—Acquired Bone Marrow Failure Diseases 

Sec. 721. Acquired bone marrow failure diseases. 

Subtitle D—Cardiovascular Disease, Chronic Disease, and Other Disease 

Issues 

Sec. 731. Guidelines for disease screening for minority patients. 

Sec. 732. CDC Wisewoman Screening Program. 

Sec. 733. Report on cardiovascular care for women and minorities. 

Sec. 734. Coverage of comprehensive tobacco cessation services in Medicaid and 

private health insurance. 

Sec. 735. Clinical research funding for oral health. 

Sec. 736. Participation by Medicaid beneficiaries in approved clinical trials. 

Subtitle E—HIV/AIDS 

Sec. 741. Statement of policy. 

Sec. 742. Findings. 

Sec. 743. Additional funding for AIDS drug assistance program treatments. 

Sec. 744. Enhancing the national HIV surveillance system. 

Sec. 745. Evidence-based strategies for improving linkage to and retention in 

appropriate care. 

Sec. 746. Improving entry into and retention in care and antiretroviral adherence for persons with HIV. 

Sec. 747. Services to reduce HIV/AIDS in racial and ethnic minority communities. 

Sec. 748. Minority AIDS initiative. 

Sec. 749. Health care professionals treating individuals with HIV/AIDS. 

Sec. 750. HIV/AIDS provider loan repayment program. 

Sec. 751. Dental education loan repayment program. 

Sec. 752. Reducing new HIV infections among injecting drug users. 

Sec. 753. Report on impact of HIV/AIDS in vulnerable populations. 

Sec. 754. National HIV/AIDS observance days. 

Sec. 755. Review of all Federal and State laws, policies, and regulations regarding the criminal prosecution of individuals for HIV-related offenses. 

Sec. 756. Expanding support for condoms in prisons. 

Sec. 757. Automatic reinstatement or enrollment in Medicaid for people who 

test positive for HIV before reentering communities. 

Sec. 758. Stop AIDS in prison. 

Sec. 759. Support data system review and indicators for monitoring HIV care. 

Sec. 760. Transfer of funds for implementation of national HIV/AIDS strategy. 

Sec. 761. Report on the implementation of goal 4 (improved coordination) of 

the national HIV/AIDS strategy. 

Subtitle F—Diabetes 

Sec. 771. Research, treatment, and education. 

Sec. 772. Research, education, and other activities. 

Sec. 773. Research, education, and other activities. 

Sec. 774. Research, education, and other activities. 

Sec. 775. Updated report on health disparities. 


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Subtitle G—Lung Disease 

Sec. 776. Expansion of the National Asthma Education and Prevention Program. 

Sec. 777. Asthma-related activities of the Centers for Disease Control and Prevention. 

Sec. 778. Influenza and pneumonia vaccination campaign. 

Sec. 779. Chronic obstructive pulmonary disease action plan. 

Subtitle H—Tuberculosis 

Sec. 781. Elimination of all forms of tuberculosis. 

Sec. 782. Additional funding for States in combating and eliminating tuberculosis. 

Sec. 783. Strengthening clinical research funding for tuberculosis. 

Subtitle I—Osteoarthritis and Musculoskeletal Diseases 

Sec. 785. Findings. 

Sec. 786. Osteoarthritis and other musculoskeletal health-related activities of 

the Centers for Disease Control and Prevention. 

Sec. 787. Grants for comprehensive osteoarthritis and musculoskeletal disease 

health education within health professions schools. 

Subtitle J—Sleep and Circadian Rhythm Disorders 

Sec. 791. Short title; findings. 

Sec. 792. Sleep and circadian rhythm disorders research activities of the National Institutes of Health. 

Sec. 793. Sleep and circadian rhythm health disparities-related activities of the 

Centers for Disease Control and Prevention. 

Sec. 794. Grants for comprehensive sleep and circadian health education within 

health professions schools. 

Sec. 795. Report on impact of sleep and circadian health disorders in vulnerable and racial/ethnic populations. 

Subtitle K—Sickle Cell Disease Research, Surveillance, Prevention, and 

Treatment 

Sec. 796. Short title. 

Sec. 796A. Sickle cell disease research. 

Sec. 796B. Sickle cell disease surveillance. 

Sec. 796C. Sickle cell disease prevention and treatment. 

Sec. 796D. Collaboration with community-based entities. 

TITLE VIII—HEALTH INFORMATION TECHNOLOGY 

Sec. 800. Definitions. 

Subtitle A—Reducing Health Disparities Through Health IT 

Sec. 801. HRSA assistance to health centers for promotion of Health IT. 

Sec. 802. Assessment of impact of Health IT on racial and ethnic minority 

communities; outreach and adoption of Health IT in such communities. 

Subtitle B—Modifications To Achieve Parity in Existing Programs 


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Sec. 811. Extending funding to strengthen the Health IT infrastructure in racial and ethnic minority communities. 

Sec. 812. Extending competitive grants for the development of loan programs 

to facilitate adoption of Certified Electronic Health Record 

Technology by providers serving racial and ethnic minority 

groups. 

Sec. 813. Authorization of appropriations. 

Subtitle C—Additional Research and Studies 

Sec. 821. Data collection and assessments conducted in coordination with minority-serving institutions. 

Sec. 822. Study of health information technology in medically underserved communities. 

Subtitle D—Closing Gaps in Funding To Adopt Certified EHRs 

Sec. 831. Extending Medicaid EHR incentive payments to rehabilitation facilities, long-term care facilities, and home health agencies. 

Sec. 832. Extending physician assistant eligibility for Medicaid electronic health 

record incentive payments. 

TITLE IX—ACCOUNTABILITY AND EVALUATION 

Sec. 901. Prohibition on discrimination in Federal assisted health care services 

and research programs on the basis of sex, race, color, national 

origin, marital status, familial status, sexual orientation, gender identity, or disability status. 

Sec. 902. Treatment of Medicare payments under title VI of the Civil Rights 

Act of 1964. 

Sec. 903. Accountability and transparency within the Department of Health 

and Human Services. 

Sec. 904. United States Commission on Civil Rights. 

Sec. 905. Sense of Congress concerning full funding of activities to eliminate 

racial and ethnic health disparities. 

Sec. 906. GAO and NIH reports. 

TITLE X—ADDRESSING SOCIAL DETERMINANTS AND IMPROVING 

ENVIRONMENTAL JUSTICE 

Subtitle A—In General 

Sec. 1001. Definitions. 

Sec. 1002. Findings. 

Sec. 1003. Health impact assessments. 

Sec. 1004. Implementation of recommendations by Environmental Protection 

Agency. 

Sec. 1005. Grant program to conduct environmental health improvement activities and to improve social determinants of health. 

Sec. 1006. Additional research on the relationship between the built environment and the health of community residents. 

Sec. 1007. Environment and public health restoration. 

Sec. 1008. GAO report on health effects of Deepwater Horizon oil rig explosion 

in the Gulf Coast. 

Subtitle B—Gun Violence 

Sec. 1011. Findings. 


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Sec. 1012. Reaffirming research authority of the Centers for Disease Control 

and Prevention. 

Sec. 1013. National violent death reporting system. 

Sec. 1014. Report on effects of gun violence on public health. 

Sec. 1015. Report on effects of gun violence on mental health in minority communities. 

1 SEC. 3. FINDINGS. 

2 The Congress finds as follows: 

3 (1) The population of racial and ethnic minori4 ties is expected to increase over the next few dec5 ades, yet racial and ethnic minorities have the poor6 est health status and face substantial cultural, so7 cial, and economic barriers to obtaining quality 

8 health care. 

9 (2) Health disparities are a function of not only 

10 access to health care, but also the social deter11 minants of health—including the environment, the 

12 physical structure of communities, nutrition and 

13 food options, educational attainment, employment, 

14 race, ethnicity, sex, geography, language preference, 

15 immigrant or citizenship status, sexual orientation, 

16 gender identity, socioeconomic status, or disability 

17 status—that directly and indirectly affect the health, 

18 health care, and wellness of individuals and commu19 nities. 

20 (3) By 2020, the Nation will face a shortage of 

21 health care providers and allied health workers and 

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1 fessional shortage areas where many racial and eth2 nic minority populations reside. 

3 (4) All efforts to reduce health disparities and 

4 barriers to quality health services require better and 

5 more consistent data. 

6 (5) A full range of culturally and linguistically 

7 appropriate health care and public health services 

8 must be available and accessible in every community. 

9 (6) Racial and ethnic minorities and under10 served populations must be included early and equi11 tably in health reform innovations. 

12 (7) Efforts to improve minority health have 

13 been limited by inadequate resources in funding, 

14 staffing, stewardship, and accountability. Targeted 

15 investments that are focused on disparities elimi16 nation must be made in providing care and services 

17 that are community-based, including prevention and 

18 policies addressing social determinants of health. 

19 (8) In 2011, the Department of Health and 

20 Human Services developed the HHS Action Plan to 

21 Reduce Racial and Ethnic Health Disparities and 

22 the National Stakeholder Strategy for Achieving 

23 Health Equity, two strategic plans that represent 

24 the country’s first coordinated roadmap to reducing 

25 health disparities. Along with the National PrevenVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 tion Strategy, Healthy People 2020, and the Na2 tional Health Care Quality Strategy, as well as crit3 ical resources such as the 2012 National Healthcare 

4 Quality and Disparities Reports, these comprehen5 sive plans will work to increase the number of Amer6 icans who are healthy at every stage of life. 

7 (9) The Department of Health and Human 

8 Services has also reviewed and advanced updated 

9 clinical guidelines and developed other strategic 

10 planning documents— 

11 (A) to combat health disparities with a 

12 high impact on minority populations including 

13 the National HIV/AIDS Strategy, the Action 

14 Plan for the Prevention, Care, and Treatment 

15 of Viral Hepatitis; and 

16 (B) to provide high-quality family planning 

17 services including recommendations of the Cen18 ters for Disease Control and Prevention and the 

19 Office of Population Affairs. 

20 (10) The Patient Protection and Affordable 

21 Care Act, as amended by the Health Care and Edu22 cation Reconciliation Act, represents the biggest ad23 vancement for minority health in the last 40 years. 


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1 TITLE I—DATA COLLECTION 

2 AND REPORTING 

3 SEC. 101. AMENDMENT TO THE PUBLIC HEALTH SERVICE 

4 ACT. 

5 (a) PURPOSE.—It is the purpose of this section to 

6 promote data collection, analysis, and reporting by race, 

7 ethnicity, sex, primary language, sexual orientation, dis8 ability status, gender identity, and socioeconomic status 

9 among federally supported health programs. 

10 (b) AMENDMENT.—Title XXXIV of the Public 

11 Health Service Act, as added by titles II and III of this 

12 Act, is further amended by inserting after subtitle A the 

13 following: 

14 ‘‘Subtitle B—Strengthening Data 

15 Collection, Improving Data 

16 Analysis, and Expanding Data 

17 Reporting 

18 ‘‘SEC. 3431. HEALTH DISPARITY DATA. 

19 ‘‘(a) REQUIREMENTS.— 

20 ‘‘(1) IN GENERAL.—Each health-related pro21 gram operated by or that receives funding or reim22 bursement, in whole or in part, either directly or in23 directly from the Department of Health and Human 

24 Services shall— 


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1 ‘‘(A) require the collection, by the agency 

2 or program involved, of data on the race, eth3 nicity, sex, primary language, sexual orienta4 tion, disability status, gender identity, and so5 cioeconomic status of each applicant for and re6 cipient of health-related assistance under such 

7 program— 

8 ‘‘(i) using, at a minimum, standards 

9 for data collection on race, ethnicity, sex, 

10 primary language, sexual orientation, dis11 ability status, gender identity, and socio12 economic status developed under section 

13 3101; 

14 ‘‘(ii) collecting data for additional 

15 population groups if such groups can be 

16 aggregated into the race and ethnicity cat17 egories outlined by standards developed 

18 under section 3101; 

19 ‘‘(iii) additionally referring, where 

20 practicable, to the standards developed by 

21 the Institute of Medicine in ‘Race, Eth22 nicity, and Language Data: Standardiza23 tion for Health Care Quality Improve24 ment’; and 


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1 ‘‘(iv) where practicable, through self2 reporting; 

3 ‘‘(B) with respect to the collection of the 

4 data described in subparagraph (A), for appli5 cants and recipients who are minors, require 

6 communication assistance in speech or writing, 

7 and for applicants and recipients who are other8 wise legally incapacitated, require that— 

9 ‘‘(i) such data be collected from the 

10 parent or legal guardian of such an appli11 cant or recipient; and 

12 ‘‘(ii) the primary language of the par13 ent or legal guardian of such an applicant 

14 or recipient be collected; 

15 ‘‘(C) systematically analyze such data 

16 using the smallest appropriate units of analysis 

17 feasible to detect racial and ethnic disparities, 

18 as well as disparities along the lines of primary 

19 language, sex, disability status, sexual orienta20 tion, gender identity, and socioeconomic status 

21 in health and health care, and report the results 

22 of such analysis to the Secretary, the Director 

23 of the Office for Civil Rights, each agency listed 

24 in section 3101(c)(1), the Committee on 

25 Health, Education, Labor, and Pensions and 


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1 the Committee on Finance of the Senate, and 

2 the Committee on Energy and Commerce and 

3 the Committee on Ways and Means of the 

4 House of Representatives; 

5 ‘‘(D) provide such data to the Secretary on 

6 at least an annual basis; and 

7 ‘‘(E) ensure that the provision of assist8 ance to an applicant or recipient of assistance 

9 is not denied or otherwise adversely affected be10 cause of the failure of the applicant or recipient 

11 to provide race, ethnicity, primary language, 

12 sex, sexual orientation, disability status, gender 

13 identity, and socioeconomic status data. 

14 ‘‘(2) RULES OF CONSTRUCTION.—Nothing in 

15 this subsection shall be construed to— 

16 ‘‘(A) permit the use of information col17 lected under this subsection in a manner that 

18 would adversely affect any individual providing 

19 any such information; or 

20 ‘‘(B) diminish existing or future require21 ments on health care providers to collect data. 

22 ‘‘(3) NO COMPELLED DISCLOSURE OF DATA.— 

23 This title does not authorize any health care pro24 vider, Federal official, or other entity to compel the 

25 disclosure of any data collected under this title. The 


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1 disclosure of any such data by an individual pursu2 ant to this title shall be strictly voluntary. 

3 ‘‘(b) PROTECTION OF DATA.—The Secretary shall 

4 ensure (through the promulgation of regulations or other5 wise) that all data collected pursuant to subsection (a) are 

6 protected— 

7 ‘‘(1) under the same privacy protections as the 

8 Secretary applies to other health data under the reg9 ulations promulgated under section 264(c) of the 

10 Health Insurance Portability and Accountability Act 

11 of 1996 (Public Law 104–191; 110 Stat. 2033) re12 lating to the privacy of individually identifiable 

13 health information and other protections; and 

14 ‘‘(2) from all inappropriate internal use by any 

15 entity that collects, stores, or receives the data, in16 cluding use of such data in determinations of eligi17 bility (or continued eligibility) in health plans, and 

18 from other inappropriate uses, as defined by the 

19 Secretary. 

20 ‘‘(c) NATIONAL PLAN OF THE DATA COUNCIL.—The 

21 Secretary shall develop and implement a national plan to 

22 ensure the collection of data in a culturally appropriate 

23 and competent manner, to improve the collection, analysis, 

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1 cioeconomic status data at the Federal, State, territorial, 

2 Tribal, and local levels, including data to be collected 

3 under subsection (a), and to ensure that data collection 

4 activities carried out under this section are in compliance 

5 with standards developed under section 3101. The Data 

6 Council of the Department of Health and Human Serv7 ices, in consultation with the National Committee on Vital 

8 Health Statistics, the Office of Minority Health, Office on 

9 Women’s Health, and other appropriate public and private 

10 entities, shall make recommendations to the Secretary 

11 concerning the development, implementation, and revision 

12 of the national plan. Such plan shall include recommenda13 tions on how to— 

14 ‘‘(1) implement subsection (a) while minimizing 

15 the cost and administrative burdens of data collec16 tion and reporting; 

17 ‘‘(2) expand knowledge among Federal agen18 cies, States, territories, Indian Tribes, counties, mu19 nicipalities, health providers, health plans, and the 

20 general public that data collection, analysis, and re21 porting by race, ethnicity, primary language, sexual 

22 orientation, disability status, gender identity, and so23 cioeconomic status is legal and necessary to assure 

24 equity and nondiscrimination in the quality of health 

25 care services; 


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1 ‘‘(3) ensure that future patient record systems 

2 follow Federal standards promulgated under the 

3 HITECH Act for the collection and meaningful use 

4 of electronic health data on race, ethnicity, primary 

5 language, sexual orientation, disability status, gen6 der identity, and socioeconomic status; 

7 ‘‘(4) improve health and health care data collec8 tion and analysis for more population groups if such 

9 groups can be aggregated into the minimum race 

10 and ethnicity categories, including exploring the fea11 sibility of enhancing collection efforts in States, 

12 counties, and municipalities for racial and ethnic 

13 groups that comprise a significant proportion of the 

14 population of the State, county, or municipality; 

15 ‘‘(5) provide researchers with greater access to 

16 racial, ethnic, primary language, sexual orientation, 

17 disability status, gender identity, and socioeconomic 

18 status data, subject to privacy and confidentiality 

19 regulations; and 

20 ‘‘(6) safeguard and prevent the misuse of data 

21 collected under subsection (a). 

22 ‘‘(d) COMPLIANCE WITH STANDARDS.—Data col23 lected under subsection (a) shall be obtained, maintained, 

24 and presented (including for reporting purposes) in ac25 cordance with standards developed under section 3101. 


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1 ‘‘(e) ANALYSIS OF HEALTH DISPARITY DATA.—The 

2 Secretary, acting through the Director of the Agency for 

3 Healthcare Research and Quality and in coordination with 

4 the Assistant Secretary for Planning and Evaluation, Ad5 ministrator of the Centers for Medicare & Medicaid Serv6 ices, the Director of the National Center for Health Statis7 tics, and the Director of the National Institutes of Health, 

8 shall provide technical assistance to agencies of the De9 partment of Health and Human Services in meeting Fed10 eral standards for health disparity data collection and for 

11 analysis of racial, ethnic, and other disparities in health 

12 and health care in public programs by— 

13 ‘‘(1) identifying appropriate quality assurance 

14 mechanisms to monitor for health disparities; 

15 ‘‘(2) specifying the clinical, diagnostic, or thera16 peutic measures which should be monitored; 

17 ‘‘(3) developing new quality measures relating 

18 to racial and ethnic disparities and their overlap 

19 with other disparity factors in health and health 

20 care; 

21 ‘‘(4) identifying the level at which data analysis 

22 should be conducted; and 

23 ‘‘(5) sharing data with external organizations 

24 for research and quality improvement purposes. 


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1 ‘‘(f) PRIMARY LANGUAGE.—References in this sec2 tion— 

3 ‘‘(1) to primary language data, include spoken 

4 and written primary language data; and 

5 ‘‘(2) to primary language data collection activi6 ties, include identifying, collecting, storing, tracking, 

7 and analyzing primary language data and informa8 tion on the methods used to meet the language ac9 cess needs of limited-English-proficient individuals. 

10 ‘‘(g) DEFINITION.—In this section, the term ‘health11 related program’ mean a program— 

12 ‘‘(1) under the Social Security Act (42 U.S.C. 

13 301 et seq.) that pays for health care and services; 

14 and 

15 ‘‘(2) under this Act that provides Federal finan16 cial assistance for health care, biomedical research, 

17 or health services research and or is designed to im18 prove the public’s health. 

19 ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There 

20 are authorized to be appropriated to carry out this section 

21 such sums as may be necessary for each of fiscal years 

22 2019 through 2024. 


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1 ‘‘SEC. 3432. ESTABLISHING GRANTS FOR DATA COLLECTION 

2 IMPROVEMENT ACTIVITIES. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Director of the Agency for Healthcare Research and 

5 Quality and in consultation with the Deputy Assistant 

6 Secretary for Minority Health, the Director of the Na7 tional Institutes of Health, the Assistant Secretary for 

8 Planning and Evaluation, and the Director of the National 

9 Center for Health Statistics, shall establish a technical as10 sistance program under which the Secretary provides 

11 grants to eligible entities to assist such entities in com12 plying with section 3431. 

13 ‘‘(b) TYPES OF ASSISTANCE.—Grants provided under 

14 this section may include grants to— 

15 ‘‘(1) enhance or upgrade computer technology 

16 that will facilitate racial, ethnic, primary language, 

17 sexual orientation, disability status, gender identity, 

18 and socioeconomic status data collection, analysis, 

19 and reporting; 

20 ‘‘(2) improve methods for health data collection 

21 and analysis, including additional population groups 

22 if such groups can be aggregated into the race and 

23 ethnicity categories outlined by standards developed 

24 under section 3101; 


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1 ‘‘(3) develop mechanisms for submitting col2 lected data subject to existing privacy and confiden3 tiality regulations; and 

4 ‘‘(4) develop educational programs to inform 

5 health plans, health providers, health-related agen6 cies, and the general public that data collection and 

7 reporting by race, ethnicity, primary language, sex8 ual orientation, disability status, gender identity, 

9 and socioeconomic status are legal and essential for 

10 eliminating health and health care disparities. 

11 ‘‘(c) ELIGIBLE ENTITY.—To be eligible for grants 

12 under this section, an entity shall be a State, territory, 

13 Indian Tribe, municipality, county, health provider, health 

14 care organization, or health plan making a demonstrated 

15 effort to bring data collections into compliance with sec16 tion 3431. 

17 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

18 are authorized to be appropriated to carry out this section 

19 such sums as may be necessary for each of fiscal years 

20 2019 through 2024. 

21 ‘‘SEC. 3433. OVERSAMPLING OF UNDERREPRESENTED 

22 GROUPS IN FEDERAL HEALTH SURVEYS. 

23 ‘‘(a) NATIONAL STRATEGY.— 

24 ‘‘(1) IN GENERAL.—The Secretary of Health 

25 and Human Services, acting through the Director of 


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1 the National Center for Health Statistics of the Cen2 ters for Disease Control and Prevention, and other 

3 agencies within the Department of Health and 

4 Human Services as the Secretary determines appro5 priate, shall develop and implement an ongoing and 

6 sustainable national strategy for oversampling 

7 underrepresented populations within the categories 

8 of race, ethnicity, sex, primary language, sexual ori9 entation, disability status, gender identity, and socio10 economic status as determined appropriate by the 

11 Secretary in Federal health surveys and program 

12 data collections. Such national strategy shall include 

13 a strategy for oversampling of Asian Americans, Na14 tive Hawaiians and Pacific Islanders. 

15 ‘‘(2) CONSULTATION.—In developing and imple16 menting a national strategy, as described in para17 graph (1), not later than 180 days after the date of 

18 the enactment of the this section, the Secretary 

19 shall— 

20 ‘‘(A) consult with representatives of com21 munity groups, nonprofit organizations, non22 governmental organizations, and government 

23 agencies working with underrepresented popu24 lations; 


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1 ‘‘(B) solicit the participation of representa2 tives from other Federal departments and agen3 cies, including subagencies of the Department 

4 of Health and Human Services; and 

5 ‘‘(C) consult on, and use as models, the 

6 2014 National Health Interview Survey over7 sample of Native Hawaiian and Pacific Islander 

8 populations and the 2017 Behavioral Risk Fac9 tor Surveillance System oversample of American 

10 Indian and Alaska Native communities. 

11 ‘‘(b) PROGRESS REPORT.—Not later than 2 years 

12 after the date of the enactment of this section, the Sec13 retary shall submit to the Congress a progress report, 

14 which shall include the national strategy described in sub15 section (a)(1). 

16 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—To 

17 carry out this section, there are authorized to be appro18 priated such sums as may be necessary for fiscal years 

19 2019 through 2024.’’. 

20 SEC. 102. ELIMINATION OF PREREQUISITE OF DIRECT AP21 PROPRIATIONS FOR DATA COLLECTION AND 

22 ANALYSIS. 

23 Section 3101 of the Public Health Service Act (42 

24 U.S.C. 300kk) is amended— 

25 (1) by striking subsection (h); and 


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1 (2) by redesignating subsection (i) as subsection 

2 (h). 

3 SEC. 103. COLLECTION OF RACE AND ETHNICITY DATA BY 

4 THE SOCIAL SECURITY ADMINISTRATION. 

5 Part A of title XI of the Social Security Act (42 

6 U.S.C. 1301 et seq.) is amended by adding at the end 

7 the following: 

8 ‘‘COLLECTION OF RACE AND ETHNICITY DATA BY THE

9 SOCIAL SECURITY ADMINISTRATION

10 ‘‘SEC. 1150C. (a) REQUIREMENT.—The Commis11 sioner of Social Security, in consultation with the Admin12 istrator of the Centers for Medicare & Medicaid Services, 

13 shall— 

14 ‘‘(1) require the collection of data on the race, 

15 ethnicity, primary language, and disability status of 

16 all applicants for Social Security account numbers or 

17 benefits under title II or part A of title XVIII and 

18 all individuals with respect to whom the Commis19 sioner maintains records of wages and self-employ20 ment income in accordance with reports received by 

21 the Commissioner or the Secretary of the Treas22 ury— 

23 ‘‘(A) using, at a minimum, standards for 

24 data collection on race, ethnicity, primary lan25 guage, and disability status developed under 

26 section 3101 of the Public Health Service Act; 


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1 ‘‘(B) where practicable, collecting data for 

2 additional population groups if such groups can 

3 be aggregated into the race and ethnicity cat4 egories outlined by standards developed under 

5 section 3101 of the Public Health Service Act; 

6 and 

7 ‘‘(C) additionally referring, where prac8 ticable, to the standards developed by the Insti9 tute of Medicine in ‘Race, Ethnicity, and Lan10 guage Data: Standardization for Health Care 

11 Quality Improvement’ (released August 31, 

12 2009); 

13 ‘‘(2) with respect to the collection of the data 

14 described in paragraph (1) for applicants who are 

15 under 18 years of age or otherwise legally incapaci16 tated, require that— 

17 ‘‘(A) such data be collected from the par18 ent or legal guardian of such an applicant; and 

19 ‘‘(B) the primary language of the parent 

20 or legal guardian of such an applicant or recipi21 ent be used in collecting the data; 

22 ‘‘(3) require that such data be uniformly ana23 lyzed and reported at least annually to the Commis24 sioner of Social Security; 


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1 ‘‘(4) be responsible for storing the data re2 ported under paragraph (3); 

3 ‘‘(5) ensure transmission to the Centers for 

4 Medicare & Medicaid Services and other Federal 

5 health agencies; 

6 ‘‘(6) provide such data to the Secretary on at 

7 least an annual basis; and 

8 ‘‘(7) ensure that the provision of assistance to 

9 an applicant is not denied or otherwise adversely af10 fected because of the failure of the applicant to pro11 vide race, ethnicity, primary language, and disability 

12 status data. 

13 ‘‘(b) PROTECTION OF DATA.—The Commissioner of 

14 Social Security shall ensure (through the promulgation of 

15 regulations or otherwise) that all data collected pursuant 

16 to subsection (a) are protected— 

17 ‘‘(1) under the same privacy protections as the 

18 Secretary applies to health data under the regula19 tions promulgated under section 264(c) of the 

20 Health Insurance Portability and Accountability Act 

21 of 1996 (Public Law 104–191; 110 Stat. 2033) re22 lating to the privacy of individually identifiable 

23 health information and other protections; and 

24 ‘‘(2) from all inappropriate internal use by any 

25 entity that collects, stores, or receives the data, inVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 cluding use of such data in determinations of eligi2 bility (or continued eligibility) in health plans, and 

3 from other inappropriate uses, as defined by the 

4 Secretary. 

5 ‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec6 tion shall be construed to permit the use of information 

7 collected under this section in a manner that would ad8 versely affect any individual providing any such informa9 tion. 

10 ‘‘(d) TECHNICAL ASSISTANCE.—The Secretary may, 

11 either directly or by grant or contract, provide technical 

12 assistance to enable any health entity to comply with the 

13 requirements of this section. 

14 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

15 are authorized to be appropriated to carry out this section 

16 such sums as may be necessary for each of fiscal years 

17 2019 through 2024.’’. 

18 SEC. 104. REVISION OF HIPAA CLAIMS STANDARDS. 

19 (a) IN GENERAL.—Not later than 1 year after the 

20 date of enactment of this Act, the Secretary of Health and 

21 Human Services shall revise the regulations promulgated 

22 under part C of title XI of the Social Security Act (42 

23 U.S.C. 1320d et seq.), relating to the collection of data 

24 on race, ethnicity, and primary language in a health-re25 lated transaction, to require— 


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1 (1) the use, at a minimum, of standards for 

2 data collection on race, ethnicity, primary language, 

3 disability, sex, sexual orientation, and gender iden4 tity developed under section 3101 of the Public 

5 Health Service Act (42 U.S.C. 300kk); and 

6 (2) in consultation with the Office of the Na7 tional Coordinator for Health Information Tech8 nology, the designation of the appropriate racial, 

9 ethnic, primary language, disability, sex, and other 

10 code sets as required for claims and enrollment data. 

11 (b) DISSEMINATION.—The Secretary of Health and 

12 Human Services shall disseminate the new standards de13 veloped under subsection (a) to all health entities that are 

14 subject to the regulations described in such subsection and 

15 provide technical assistance with respect to the collection 

16 of the data involved. 

17 (c) COMPLIANCE.—The Secretary of Health and 

18 Human Services shall require that health entities comply 

19 with the new standards developed under subsection (a) not 

20 later than 2 years after the final promulgation of such 

21 standards. 

22 SEC. 105. NATIONAL CENTER FOR HEALTH STATISTICS. 

23 Section 306(n) of the Public Health Service Act (42 

24 U.S.C. 242k(n)) is amended— 


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1 (1) in paragraph (1), by striking ‘‘2003’’ and 

2 inserting ‘‘2022’’; 

3 (2) in paragraph (2), in the first sentence, by 

4 striking ‘‘2003’’ and inserting ‘‘2022’’; and 

5 (3) in paragraph (3), by striking ‘‘2002’’ and 

6 inserting ‘‘2022’’. 

7 SEC. 106. DISPARITIES DATA COLLECTED BY THE FEDERAL 

8 GOVERNMENT. 

9 (a) COLLECTION; SUBMISSION.—Not later than 180 

10 days after the date of the enactment of this Act, and Jan11 uary 31 of each year thereafter, each department, agency, 

12 and office of the Federal Government that has collected 

13 data on race, ethnicity, sex, primary language, sexual ori14 entation, disability status, gender identity, or socio15 economic status during the preceding calendar year shall 

16 submit such data to a centralized electronic repository of 

17 Government data on factors related to the health and well18 being of the American population. 

19 (b) ANALYSIS; PUBLIC AVAILABILITY; REPORTING.— 

20 Not later than April 30, 2018, and each April 30 there21 after, the Secretary of Health and Human Services, acting 

22 through the Assistant Secretary for Planning and Evalua23 tion, the Assistant Secretary for Health, the Director of 

24 the Agency for Healthcare Research and Quality, the Di25 rector of the National Center for Health Statistics, the 


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1 Administrator of the Centers for Medicare & Medicaid 

2 Services, the Director of the National Institute on Minor3 ity Health and Health Disparities, and the Deputy Assist4 ant Secretary for Minority Health, shall— 

5 (1) prepare and make available datasets for 

6 public use that relate to disparities in health status, 

7 health care access, health care quality, health out8 comes, public health, and other areas of health and 

9 well-being by factors that include race, ethnicity, 

10 sex, primary language, sexual orientation, disability 

11 status, gender identity, and socioeconomic status; 

12 (2) ensure that these data sets are publicly 

13 identified on a centralized electronic repository of 

14 Government data as ‘‘disparities’’ data; and 

15 (3) submit a report to the Congress on the 

16 availability and use of such data by public stake17 holders. 

18 SEC. 107. DATA COLLECTION AND ANALYSIS GRANTS TO MI19 NORITY-SERVING INSTITUTIONS. 

20 (a) AUTHORITY.—The Secretary of Health and 

21 Human Services, acting through the National Institute on 

22 Minority Health and Health Disparities and the Deputy 

23 Assistant Secretary for Minority Health, shall award 

24 grants to access and analyze racial and ethnic, and where 

25 possible other health disparity data, to monitor and report 


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1 on progress to reduce and eliminate disparities in health 

2 and health care. 

3 (b) ELIGIBLE ENTITY.—In this section, the term ‘‘el4 igible entity’’ means a historically Black college or univer5 sity, a Hispanic-serving institution, a Tribal college or uni6 versity, or an Asian American, Native American, or Pacific 

7 Islander-serving institution with an accredited public 

8 health, health policy, or health services research program. 

9 (c) AUTHORIZATION OF APPROPRIATIONS.—To carry 

10 out this section, there are authorized to be appropriated 

11 such sums as may be necessary for fiscal years 2019 

12 through 2024. 

13 SEC. 108. STANDARDS FOR MEASURING SEXUAL ORIENTA14 TION AND GENDER IDENTITY IN COLLECTION 

15 OF HEALTH DATA. 

16 Section 3101(a) of the Public Health Service Act (42 

17 U.S.C. 300kk(a)) is amended— 

18 (1) in paragraph (1)(A), by inserting ‘‘sexual 

19 orientation, gender identity,’’ before ‘‘and disability 

20 status’’; 

21 (2) in paragraph (1)(C), by inserting ‘‘sexual 

22 orientation, gender identity,’’ before ‘‘and disability 

23 status’’; and 


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1 (3) in paragraph (2)(B), by inserting ‘‘sexual 

2 orientation, gender identity,’’ before ‘‘and disability 

3 status’’. 

4 SEC. 109. STANDARDS FOR MEASURING SOCIOECONOMIC 

5 STATUS IN COLLECTION OF HEALTH DATA. 

6 Section 3101(a) of the Public Health Service Act (42 

7 U.S.C. 300kk(a)), as amended, is amended— 

8 (1) in paragraph (1)(A), by inserting ‘‘socio9 economic status,’’ before ‘‘and disability status’’; 

10 (2) in paragraph (1)(C), by inserting ‘‘socio11 economic status,’’ before ‘‘and disability status’’; and 

12 (3) in paragraph (2)(B), by inserting ‘‘socio13 economic status,’’ before ‘‘and disability status’’. 

14 SEC. 110. SAFETY AND EFFECTIVENESS OF DRUGS WITH 

15 RESPECT TO RACIAL AND ETHNIC BACK16 GROUND. 

17 (a) IN GENERAL.—Chapter V of the Federal Food, 

18 Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) is amend19 ed by adding after section 505F the following: 

20 ‘‘SEC. 505G. SAFETY AND EFFECTIVENESS OF DRUGS WITH 

21 RESPECT TO RACIAL AND ETHNIC BACK22 GROUND. 

23 ‘‘(a) PREAPPROVAL STUDIES.—If there is evidence 

24 that there may be a disparity on the basis of racial or 


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1 ethnic background as to the safety or effectiveness of a 

2 drug, then— 

3 ‘‘(1)(A) the investigations required under sec4 tion 505(b)(1)(A) shall include adequate and well5 controlled investigations of the disparity; or 

6 ‘‘(B) the evidence required under section 351(a) 

7 of the Public Health Service Act for approval of a 

8 biologics license application for the drug shall in9 clude adequate and well-controlled investigations of 

10 the disparity; and 

11 ‘‘(2) if the investigations confirm that there is 

12 a disparity, the labeling of the drug shall include ap13 propriate information about the disparity. 

14 ‘‘(b) POSTMARKET STUDIES.— 

15 ‘‘(1) IN GENERAL.—If there is evidence that 

16 there may be a disparity on the basis of racial or 

17 ethnic background as to the safety or effectiveness 

18 of a drug for which there is an approved application 

19 under section 505 or a license under section 351 of 

20 the Public Health Service Act, the Secretary may by 

21 order require the holder of the approved application 

22 or license to conduct, by a date specified by the Sec23 retary, postmarketing studies to investigate the dis24 parity. 


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1 ‘‘(2) LABELING.—If the Secretary determines 

2 that the postmarket studies confirm that there is a 

3 disparity described in paragraph (1), the labeling of 

4 the drug shall include appropriate information about 

5 the disparity. 

6 ‘‘(3) STUDY DESIGN.—The Secretary may 

7 specify all aspects of study design, including the 

8 number of studies and study participants, and the 

9 other demographic characteristics of study partici10 pants included, in the order requiring postmarket 

11 studies of the drug. 

12 ‘‘(4) MODIFICATIONS OF STUDY DESIGN.—The 

13 Secretary may by order modify any aspect of the 

14 study design as necessary after issuing an order 

15 under paragraph (1). 

16 ‘‘(5) STUDY RESULTS.—The results from stud17 ies required under paragraph (1) shall be submitted 

18 to the Secretary as supplements to the drug applica19 tion or biological license application. 

20 ‘‘(c) DISPARITY.—The term ‘evidence that there may 

21 be a disparity on the basis of racial or ethnic background 

22 for adult and pediatric populations as to the safety or ef23 fectiveness of a drug’ includes— 

24 ‘‘(1) evidence that there is a disparity on the 

25 basis of racial or ethnic background as to safety or 


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1 effectiveness of a drug in the same chemical class as 

2 the drug; 

3 ‘‘(2) evidence that there is a disparity on the 

4 basis of racial or ethnic background in the way the 

5 drug is metabolized; and 

6 ‘‘(3) other evidence as the Secretary may deter7 mine. 

8 ‘‘(d) APPLICATIONS UNDER SECTIONS 505(b)(2) 

9 AND 505(j).— 

10 ‘‘(1) IN GENERAL.—A drug for which an appli11 cation has been submitted or approved under section 

12 505(j) shall not be considered ineligible for approval 

13 under that section or misbranded under section 502 

14 on the basis that the labeling of the drug omits in15 formation relating to a disparity on the basis of ra16 cial or ethnic background as to the safety or effec17 tiveness of the drug, whether derived from investiga18 tions or studies required under this section or de19 rived from other sources, when the omitted informa20 tion is protected by patent or by exclusivity under 

21 clause (iii) or (iv) of section 505(j)(5)(B). 

22 ‘‘(2) LABELING.—Notwithstanding clauses (iii) 

23 and (iv) of section 505(j)(5)(B), the Secretary may 

24 require that the labeling of a drug approved under 

25 section 505(j) that omits information relating to a 


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1 disparity on the basis of racial or ethnic background 

2 as to the safety or effectiveness of the drug include 

3 a statement of any appropriate contraindications, 

4 warnings, or precautions related to the disparity 

5 that the Secretary considers necessary.’’. 

6 (b) ENFORCEMENT.—Section 502 of the Federal 

7 Food, Drug, and Cosmetic Act (21 U.S.C. 352) is amend8 ed by adding at the end the following: 

9 ‘‘(ee) If it is a drug and the holder of the approved 

10 application under section 505 or license under section 351 

11 of the Public Health Service Act for the drug has failed 

12 to complete the investigations or studies, or comply with 

13 any other requirement, of section 505G.’’. 

14 (c) DRUG FEES.—Section 736(a)(1)(A)(ii) of the 

15 Federal Food, Drug, and Cosmetic Act (21 U.S.C. 379h) 

16 is amended by adding after ‘‘are required’’ the following: 

17 ‘‘, including supplements required under section 505G’’. 

18 SEC. 111. IMPROVING HEALTH DATA REGARDING NATIVE 

19 HAWAIIANS AND OTHER PACIFIC ISLANDERS. 

20 Part B of title III of the Public Health Service Act 

21 (42 U.S.C. 243 et seq.) is amended by inserting after sec22 tion 317U, as added, the following: 

23 ‘‘SEC. 317V. NATIVE HAWAIIAN AND OTHER PACIFIC IS24 LANDER HEALTH DATA. 

25 ‘‘(a) DEFINITIONS.—In this section: 


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1 ‘‘(1) COMMUNITY GROUP.—The term ‘commu2 nity group’ means a group of NHOPI who are orga3 nized at the community level, and may include a 

4 church group, social service group, national advocacy 

5 organization, or cultural group. 

6 ‘‘(2) NONPROFIT, NONGOVERNMENTAL ORGANI7 ZATION.—The term ‘nonprofit, nongovernmental or8 ganization’ means a group of NHOPI with a dem9 onstrated history of addressing NHOPI issues, in10 cluding a NHOPI coalition. 

11 ‘‘(3) DESIGNATED ORGANIZATION.—The term 

12 ‘designated organization’ means an entity estab13 lished to represent NHOPI populations and which 

14 has statutory responsibilities to provide, or has com15 munity support for providing, health care. 

16 ‘‘(4) GOVERNMENT REPRESENTATIVES.—The 

17 term ‘government representatives’ means representa18 tives from Hawaii, American Samoa, the Common19 wealth of the Northern Mariana Islands, the Fed20 erated States of Micronesia, Guam, the Republic of 

21 Palau, and the Republic of the Marshall Islands. 

22 ‘‘(5) NATIVE HAWAIIANS AND OTHER PACIFIC

23 ISLANDERS (NHOPI).—The term ‘Native Hawaiians 

24 and Other Pacific Islanders’ or ‘NHOPI’ means peo25 ple having origins in any of the original peoples of 


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1 American Samoa, the Commonwealth of the North2 ern Mariana Islands, the Federated States of Micro3 nesia, Guam, Hawaii, the Republic of the Marshall 

4 Islands, the Republic of Palau, or any other Pacific 

5 island. 

6 ‘‘(6) INSULAR AREA.—The term ‘insular area’ 

7 means Guam, the Commonwealth of Northern Mar8 iana Islands, American Samoa, the United States 

9 Virgin Islands, the Federated States of Micronesia, 

10 the Republic of Palau, or the Republic of the Mar11 shall Islands. 

12 ‘‘(b) NATIONAL STRATEGY.— 

13 ‘‘(1) IN GENERAL.—The Secretary, acting 

14 through the Director of the National Center for 

15 Health Statistics (referred to in this section as 

16 ‘NCHS’) of the Centers for Disease Control and 

17 Prevention, and other agencies within the Depart18 ment of Health and Human Services as the Sec19 retary determines appropriate, shall develop and im20 plement an ongoing and sustainable national strat21 egy for identifying and evaluating the health status 

22 and health care needs of NHOPI populations living 

23 in the continental United States, Hawaii, American 

24 Samoa, the Commonwealth of the Northern Mariana 

25 Islands, the Federated States of Micronesia, Guam, 


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1 the Republic of Palau, and the Republic of the Mar2 shall Islands. 

3 ‘‘(2) CONSULTATION.—In developing and imple4 menting a national strategy, as described in para5 graph (1), not later than 180 days after the date of 

6 enactment of the Health Equity and Accountability 

7 Act of 2018, the Secretary— 

8 ‘‘(A) shall consult with representatives of 

9 community groups, designated organizations, 

10 and nonprofit, nongovernmental organizations 

11 and with government representatives of NHOPI 

12 populations; and 

13 ‘‘(B) may solicit the participation of rep14 resentatives from other Federal departments. 

15 ‘‘(c) PRELIMINARY HEALTH SURVEY.— 

16 ‘‘(1) IN GENERAL.—The Secretary, acting 

17 through the Director of NCHS, shall conduct a pre18 liminary health survey in order to identify the major 

19 areas and regions in the continental United States, 

20 Hawaii, American Samoa, the Commonwealth of the 

21 Northern Mariana Islands, the Federated States of 

22 Micronesia, Guam, the Republic of Palau, and the 

23 Republic of the Marshall Islands in which NHOPI 

24 people reside. 


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1 ‘‘(2) CONTENTS.—The health survey described 

2 in paragraph (1) shall include health data and any 

3 other data the Secretary determines to be— 

4 ‘‘(A) useful in determining health status 

5 and health care needs; or 

6 ‘‘(B) required for developing or imple7 menting a national strategy. 

8 ‘‘(3) METHODOLOGY.—Methodology for the 

9 health survey described in paragraph (1), including 

10 plans for designing questions, implementation, sam11 pling, and analysis, shall be developed in consulta12 tion with community groups, designated organiza13 tions, nonprofit, nongovernmental organizations, and 

14 government representatives of NHOPI populations, 

15 as determined by the Secretary. 

16 ‘‘(4) TIMEFRAME.—The survey required under 

17 this subsection shall be completed not later than 18 

18 months after the date of enactment of the Health 

19 Equity and Accountability Act of 2018. 

20 ‘‘(d) PROGRESS REPORT.—Not later than 2 years 

21 after the date of enactment of the Health Equity and Ac22 countability Act of 2018, the Secretary shall submit to 

23 Congress a progress report, which shall include the na24 tional strategy described in subsection (b)(1). 

25 ‘‘(e) STUDY AND REPORT BY THE IOM.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall enter 

2 into an agreement with the Institute of Medicine 

3 (IOM) to conduct a study, with input from stake4 holders in insular areas, on the following: 

5 ‘‘(A) The standards and definitions of 

6 health care applied to health care systems in in7 sular areas and the appropriateness of such 

8 standards and definitions. 

9 ‘‘(B) The status and performance of health 

10 care systems in insular areas, evaluated based 

11 upon standards and definitions, as the Sec12 retary determines. 

13 ‘‘(C) The effectiveness of donor aid in ad14 dressing health care needs and priorities in in15 sular areas. 

16 ‘‘(D) The progress toward implementation 

17 of recommendations of the Committee on 

18 Health Care Services in the United States—As19 sociated Pacific Basin of the Institute of Medi20 cine that are set forth in the 1998 report, ‘Pa21 cific Partnerships for Health: Charting a New 

22 Course for the 21st Century’. 

23 ‘‘(2) REPORT.—An agreement described in 

24 paragraph (1) shall require the Institute of Medicine 

25 to submit to the Secretary and to Congress, not 


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1 later than 2 years after the date of the enactment 

2 of the Health Equity and Accountability Act of 

3 2018, a report containing a description of the results 

4 of the study conducted under paragraph (1), includ5 ing the conclusions and recommendations of the In6 stitute of Medicine for each of the items described 

7 in subparagraphs (A) through (D) of such para8 graph. 

9 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—To 

10 carry out this section, there are authorized to be appro11 priated such sums as may be necessary for fiscal years 

12 2019 through 2024.’’. 

13 SEC. 112. CLARIFICATION OF SIMPLIFIED ADMINISTRATIVE 

14 REPORTING REQUIREMENT. 

15 Section 11(a) of the Food and Nutrition Act of 2008 

16 (7 U.S.C. 2020(a)) is amended by adding at the end the 

17 following: 

18 ‘‘(5) SIMPLIFIED ADMINISTRATIVE REPORTING

19 REQUIREMENT.—The administrative notification re20 quirement under section 421(e)(2) of the Personal 

21 Responsibility and Work Opportunity Reconciliation 

22 Act of 1996 (8 U.S.C. 1631(e)(2)) shall be satisfied 

23 by the submission by an agency of a report on the 

24 aggregate number of exceptions granted under such 

25 section by such agency in each year.’’. 


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1 TITLE II—CULTURALLY AND LIN2 GUISTICALLY APPROPRIATE 

3 HEALTH AND HEALTH CARE 

4 SEC. 201. DEFINITIONS. 

5 In this title, the definitions contained in section 3400 

6 of the Public Health Service Act, as added by section 202, 

7 shall apply. 

8 SEC. 202. AMENDMENT TO THE PUBLIC HEALTH SERVICE 

9 ACT. 

10 (a) FINDINGS.—Congress finds the following: 

11 (1) Effective communication is essential to 

12 meaningful access to quality physical and mental 

13 health care. 

14 (2) Research indicates that the lack of appro15 priate language services creates language barriers 

16 that result in increased risk of misdiagnosis, ineffec17 tive treatment plans and poor health outcomes for 

18 limited-English-proficient individuals and individuals 

19 with communication disabilities such as hearing, vi20 sion, or print impairments. 

21 (3) The number of limited-English-speaking 

22 residents in the United States who speak English 

23 less than very well and, therefore, cannot effectively 

24 communicate with health and social service providers 

25 continues to increase significantly. 


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1 (4) The responsibility to fund language services 

2 in the provision of health care and health-care-re3 lated services to limited-English-proficient individ4 uals and individuals with communication disabilities 

5 such as hearing, vision, or print impairments is a so6 cietal one that cannot fairly be visited solely upon 

7 the health care, public health, or social services com8 munity. 

9 (5) Title VI of the Civil Rights Act of 1964 

10 prohibits discrimination based on the grounds of 

11 race, color, or national origin by any entity receiving 

12 Federal financial assistance. In order to avoid dis13 crimination on the grounds of national origin, all 

14 programs or activities administered by the Depart15 ment must take adequate steps to ensure that their 

16 policies and procedures do not deny or have the ef17 fect of denying limited-English-proficient individuals 

18 with equal access to benefits and services for which 

19 such persons qualify. 

20 (6) Both the Americans with Disabilities Act 

21 and the Rehabilitation Act of 1973 prohibit discrimi22 nation on the basis of disability and require the pro23 vision of appropriate auxiliary aids and services nec24 essary to ensure effective communication with indi25 viduals with disabilities. The type of auxiliary aid or 


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1 service necessary to ensure effective communication 

2 will vary in accordance with the method of commu3 nication used by the individual; the nature, length, 

4 and complexity of the communication involved; and 

5 the context in which the communication is taking 

6 place. A public accommodation should consult with 

7 individuals with disabilities whenever possible to de8 termine what type of auxiliary aid is needed to en9 sure effective communication, but the ultimate deci10 sion as to what measures to take rests with the pub11 lic accommodation, provided that the method chosen 

12 results in effective communication. In order to be ef13 fective, auxiliary aids and services must be provided 

14 in accessible formats, in a timely manner, and in 

15 such a way as to protect the privacy and independ16 ence of the individual with a disability. 

17 (7) Linguistic diversity in the health care and 

18 health-care-related-services workforce is important 

19 for providing all patients the environment most con20 ducive to positive health outcomes. 

21 (8) All members of the health care and health22 care-related-services community should continue to 

23 educate their staff and constituents about limited24 English-proficient and disability communication 

25 issues and help them identify resources to improve 


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1 access to quality care for limited-English-proficient 

2 individuals and individuals with communication dis3 abilities such as hearing, vision, or print impair4 ments. 

5 (9) Access to English as a second language, and 

6 sign language instructions, readers, and other auxil7 iary aids and services, are essential to ensure effec8 tive communication and eliminate the language bar9 riers that impede access to health care. 

10 (10) Competent language services in health care 

11 settings should be available as a matter of course. 

12 (b) AMENDMENT.—The Public Health Service Act 

13 (42 U.S.C. 201 et seq.) is amended by adding at the end 

14 the following: 

15 ‘‘TITLE XXXIV—CULTURALLY 

16 AND LINGUISTICALLY APPRO17 PRIATE HEALTH CARE 

18 ‘‘SEC. 3400. DEFINITIONS. 

19 ‘‘In this title: 

20 ‘‘(1) BILINGUAL.—The term ‘bilingual’ with re21 spect to an individual means a person who has suffi22 cient degree of proficiency in two languages. 

23 ‘‘(2) CULTURAL COMPETENCE.—The term ‘cul24 tural competence’ means a set of congruent behav25 iors, attitudes, and policies that come together in a 


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1 system, agency, or among professionals that enables 

2 effective work in cross-cultural situations. In the 

3 preceding sentence— 

4 ‘‘(A) the term ‘cultural’ refers to inte5 grated patterns of human behavior that include 

6 the language, thoughts, communications, ac7 tions, customs, beliefs, values, and institutions 

8 of racial, ethnic, religious, or social groups, in9 cluding lesbian, gay, bisexual, transgender, 

10 queer, and questioning individuals, and individ11 uals with physical and mental disabilities; and 

12 ‘‘(B) the term ‘competence’ implies having 

13 the capacity to function effectively as an indi14 vidual and an organization within the context of 

15 the cultural beliefs, behaviors, and needs pre16 sented by consumers and their communities. 

17 ‘‘(3) EFFECTIVE COMMUNICATION.—The term 

18 ‘effective communication’ means an exchange of in19 formation between the provider of health care or 

20 health-care-related services and the recipient of such 

21 services who is limited in English proficiency, or has 

22 a communication impairment such as a hearing, vi23 sion, speaking, or learning impairment, that enables 

24 access, understanding, and benefit from health care 


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1 or health-care-related services, and full participation 

2 in the development of their treatment plan. 

3 ‘‘(4) GRIEVANCE RESOLUTION PROCESS.—The 

4 term ‘grievance resolution process’ means all aspects 

5 of dispute resolution including filing complaints, 

6 grievance and appeal procedures, and court action. 

7 ‘‘(5) HEALTH CARE GROUP.—The term ‘health 

8 care group’ means a group of physicians organized, 

9 at least in part, for the purposes of providing physi10 cians’ services under the Medicaid, SCHIP, or Medi11 care programs and may include a hospital and any 

12 other individual or entity furnishing services covered 

13 under the Medicaid, SCHIP, or Medicare programs 

14 that is affiliated with the health care group. 

15 ‘‘(6) HEALTH EDUCATOR.—The term ‘health 

16 educator’ includes a baccalaureate prepared profes17 sional responsible for designing, implementing, and 

18 evaluating individual and population health pro19 motion and chronic disease prevention programs. 

20 ‘‘(7) HEALTH CARE SERVICES.—The term 

21 ‘health care services’ means services that address 

22 physical as well as mental health conditions in all 

23 care settings. 

24 ‘‘(8) HEALTH-CARE-RELATED SERVICES.—The 

25 term ‘health-care-related services’ means human or 


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1 social services programs or activities that provide ac2 cess, referrals or links to health care. 

3 ‘‘(9) INDIAN TRIBE.—The term ‘Indian Tribe’ 

4 means any Indian Tribe, band, nation, or other or5 ganized group or community, including any Alaska 

6 Native village or group or regional or village cor7 poration as defined in or established pursuant to the 

8 Alaska Native Claims Settlement Act (85 Stat. 688) 

9 (43 U.S.C. 1601 et seq.), which is recognized as eli10 gible for the special programs and services provided 

11 by the United States to Indians because of their sta12 tus as Indians. 

13 ‘‘(10) INTEGRATED HEALTH CARE DELIVERY

14 SYSTEM.—The term ‘integrated health care delivery 

15 system’ means an interdisciplinary system that 

16 brings together providers from the primary health, 

17 mental health, substance use and related disciplines 

18 to improve the health outcomes of an individual. 

19 Providers may include but are not limited to hos20 pitals, health, mental health or substance use clinics 

21 and providers, home health agencies, ambulatory 

22 surgery centers, skilled nursing facilities, rehabilita23 tion centers, and employed, independent, or con24 tracted physicians. 


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1 ‘‘(11) INDIVIDUAL WITH A DISABILITY.—The 

2 term ‘individual with a disability’ means any indi3 vidual who has a disability as defined for the pur4 pose of section 504 of the Rehabilitation Act of 

5 1973. Where this title references regulatory provi6 sions applicable to a ‘handicapped individual’, the 

7 term ‘handicapped individual’ in such provisions 

8 shall be treated to have the same meaning as the 

9 term ‘individual with a disability’ as defined in this 

10 section. 

11 ‘‘(12) INDIVIDUAL WITH LIMITED-ENGLISH

12 PROFICIENCY.—The term ‘individual with limited13 English proficiency’ means an individual whose pri14 mary language for communication is not English 

15 and who has a limited ability to read, write, speak, 

16 or understand English. 

17 ‘‘(13) INTERPRETING; INTERPRETATION.—The 

18 terms ‘interpreting’ and ‘interpretation’ mean the 

19 transmission of a spoken, written, or signed message 

20 from one language or format into another, faithfully, 

21 accurately, and objectively. 

22 ‘‘(14) LANGUAGE ACCESS.—The term ‘language 

23 access’ means the provision of language services to 

24 an individual with limited-English proficiency or an 

25 individual with communication disabilities designed 


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1 to enhance that individual’s access to, understanding 

2 of, or benefit from health care or health-care-related 

3 services. 

4 ‘‘(15) LANGUAGE ASSISTANCE SERVICES.—The 

5 term ‘language assistance services’ includes— 

6 ‘‘(A) oral language assistance, including in7 terpretation in non-English languages provided 

8 in-person or remotely by a qualified interpreter 

9 for an individual with limited-English pro10 ficiency, and the use of qualified bilingual or 

11 multilingual staff to communicate directly with 

12 individuals with limited-English proficiency; 

13 ‘‘(B) written translation, performed by a 

14 qualified translator, of written content in paper 

15 or electronic form into languages other than 

16 English; and 

17 ‘‘(C) taglines. 

18 ‘‘(16) MEDICARE, MEDICAID, AND SCHIP.—The 

19 terms ‘Medicare’, ‘Medicaid’, and ‘SCHIP’ mean the 

20 respective programs under titles XVIII, XIX, and 

21 XXI of the Social Security Act. 

22 ‘‘(17) MINORITY.— 

23 ‘‘(A) IN GENERAL.—The terms ‘minority’ 

24 and ‘minorities’ refer to individuals from a mi25 nority group. 


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1 ‘‘(B) POPULATIONS.—The term ‘minority’, 

2 with respect to populations, refers to racial and 

3 ethnic minority groups, members of sexual and 

4 gender minority groups, and individuals with a 

5 disability. 

6 ‘‘(18) MINORITY GROUP.—The term ‘minority 

7 group’ has the meaning given the term ‘racial and 

8 ethnic minority group’. 

9 ‘‘(19) QUALIFIED INTERPRETER FOR AN INDI10 VIDUAL WITH LIMITED-ENGLISH PROFICIENCY.— 

11 The term ‘qualified interpreter for an individual with 

12 limited-English proficiency’ means an interpreter 

13 who via a remote interpreting service or an on-site 

14 appearance— 

15 ‘‘(A) adheres to generally accepted inter16 preter ethics principles, including client con17 fidentiality; 

18 ‘‘(B) has demonstrated proficiency in 

19 speaking and understanding both spoken 

20 English and one or more other spoken lan21 guages; and 

22 ‘‘(C) is able to interpret effectively, accu23 rately, and impartially, both receptively and ex24 pressly, to and from such languages and 


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1 English, using any necessary specialized vocab2 ulary, terminology, and phraseology. 

3 ‘‘(20) QUALIFIED TRANSLATOR.—The term 

4 ‘qualified translator’ means a translator who— 

5 ‘‘(A) adheres to generally accepted trans6 lator ethics principles, including client confiden7 tiality; 

8 ‘‘(B) has demonstrated proficiency in writ9 ing and understanding both written English 

10 and one or more other written non-English lan11 guages; and 

12 ‘‘(C) is able to translate effectively, accu13 rately, and impartially to and from such lan14 guages and English, using any necessary spe15 cialized vocabulary, terminology, and phrase16 ology. 

17 ‘‘(21) RACIAL AND ETHNIC MINORITY GROUP.— 

18 The term ‘racial and ethnic minority group’ means 

19 American Indians and Alaska Natives, African 

20 Americans (including Caribbean Blacks, Africans, 

21 and other Blacks), Asian Americans, Hispanics (in22 cluding Latinos), and Native Hawaiians and other 

23 Pacific Islanders. 

24 ‘‘(22) SEXUAL AND GENDER MINORITY

25 GROUP.—The term ‘sexual and gender minority 


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1 group’ encompasses lesbian, gay, bisexual, and 

2 transgender populations, as well as those whose sex3 ual orientation, gender identity and expression, or 

4 reproductive development varies from traditional, so5 cietal, cultural, or physiological norms. 

6 ‘‘(23) ONSITE INTERPRETATION.—The term 

7 ‘onsite interpretation’ means a method of inter8 preting or interpretation for which the interpreter is 

9 in the physical presence of the provider of health 

10 care or health-care-related services and the recipient 

11 of such services who is limited in English proficiency 

12 or has a communication impairment such as hear13 ing, vision, or learning. 

14 ‘‘(24) SECRETARY.—The term ‘Secretary’ 

15 means the Secretary of Health and Human Services. 

16 ‘‘(25) SIGHT TRANSLATION.—The term ‘sight 

17 translation’ means the transmission of a written 

18 message in one language into a spoken or signed 

19 message in another language, or an alternative for20 mat in English or another language. 

21 ‘‘(26) STATE.—The term ‘State’ means each of 

22 the several States, the District of Columbia, the 

23 Commonwealth of Puerto Rico, the Indian Tribes, 

24 the United States Virgin Islands, Guam, American 


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1 Samoa, and the Commonwealth of the Northern 

2 Mariana Islands. 

3 ‘‘(27) TELEPHONIC INTERPRETATION.—The 

4 term ‘telephonic interpretation’ (also known as over 

5 the phone interpretation or OPI) means a method of 

6 interpretation for which the interpreter is not in the 

7 physical presence of the provider of health care or 

8 related services and the limited-English-proficient re9 cipient of such services but is connected via tele10 phone. 

11 ‘‘(28) TRANSLATION.—The term ‘translation’ 

12 means the transmission of a written message in one 

13 language into a written or signed message in an14 other language, and includes translation into an15 other language or alternative format, such as large 

16 print font, Braille, audio recording, or CD. 

17 ‘‘(29) VIDEO REMOTE INTERPRETING SERV18 ICES.—The term ‘video remote interpreting services’ 

19 means the provision, through a qualified interpreter 

20 for an individual with limited-English proficiency, of 

21 video remote interpreting services in health pro22 grams and activities. 

23 ‘‘(A) in real-time, full-motion video, and 

24 audio over a dedicated high-speed, wide-band25 width video connection or wireless connection 


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1 that delivers high quality video images that do 

2 not produce lags, choppy, blurry, or grainy im3 ages, or irregular pauses in communication; and 

4 ‘‘(B) in a sharply delineated image that is 

5 large enough to display. 

6 ‘‘(30) VITAL DOCUMENT.—The term ‘vital doc7 ument’ includes but is not limited to applications for 

8 government programs that provide health care serv9 ices, medical or financial consent forms, financial as10 sistance documents, letters containing important in11 formation regarding patient instructions (such as 

12 prescriptions, referrals to other providers, and dis13 charge plans) and participation in a program (such 

14 as a Medicaid managed care program), notices per15 taining to the reduction, denial, or termination of 

16 services or benefits, notices of the right to appeal 

17 such actions, and notices advising limited-English18 proficient individuals and individuals with commu19 nication disabilities of the availability of free lan20 guage services, alternative formats, and other out21 reach materials. 

22 ‘‘SEC. 3401. IMPROVING ACCESS TO SERVICES FOR INDIVID23 UALS WITH LIMITED-ENGLISH PROFICIENCY. 

24 ‘‘(a) PURPOSE.—As provided in Executive Order 

25 13166, it is the purpose of this section— 


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1 ‘‘(1) to improve Federal agency performance re2 garding access to federally conducted and federally 

3 assisted programs and activities for individuals who 

4 are limited in their English proficiency; 

5 ‘‘(2) to require each Federal agency to examine 

6 the services it provides and develop and implement 

7 a system by which limited-English-proficient individ8 uals can obtain cultural competence and meaningful 

9 access to those services consistent with, and without 

10 substantially burdening, the fundamental mission of 

11 the agency; 

12 ‘‘(3) to require each Federal agency to ensure 

13 that recipients of Federal financial assistance pro14 vide cultural competence and meaningful access to 

15 their limited-English-proficient applicants and bene16 ficiaries; 

17 ‘‘(4) to ensure that recipients of Federal finan18 cial assistance take reasonable steps, consistent with 

19 the guidelines set forth in the limited-English pro20 ficient Guidance of the Department of Justice (as 

21 issued on June 12, 2002), to ensure cultural com22 petence and meaningful access to their programs 

23 and activities by limited-English-proficient individ24 uals; and 


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1 ‘‘(5) to ensure compliance with title VI of the 

2 Civil Rights Act of 1964 and that health care pro3 viders and organizations do not discriminate in the 

4 provision of services. 

5 ‘‘(b) FEDERALLY CONDUCTED PROGRAMS AND AC6 TIVITIES.— 

7 ‘‘(1) IN GENERAL.—Not later than 120 days 

8 after the date of enactment of this title, each Fed9 eral agency that carries out health-care-related ac10 tivities shall prepare a plan to improve access cul11 tural competence to the federally conducted, health12 care-related programs and activities of the agency by 

13 limited-English-proficient individuals. Not later than 

14 one year after the date of enactment of this title, 

15 each such Federal agency shall ensure that such 

16 plan is fully implemented. 

17 ‘‘(2) PLAN REQUIREMENT.—Each plan under 

18 paragraph (1) shall include— 

19 ‘‘(A) the steps the agency will take to en20 sure that limited-English-proficient individuals 

21 have access to the agency’s federally conducted 

22 health care and health-care-related programs 

23 and activities; 

24 ‘‘(B) the policies and procedures for identi25 fying, assessing, and meeting the language 


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1 needs and cultural competence needs of its lim2 ited-English-proficient beneficiaries served by 

3 federally conducted programs and activities; 

4 ‘‘(C) the steps the agency will take for its 

5 federally conducted programs and activities to 

6 improve cultural competence to provide a range 

7 of language assistance options, notice to lim8 ited-English-proficient individuals of the right 

9 to competent language services, periodic train10 ing of staff, monitoring and quality assessment 

11 of the language services and, in appropriate cir12 cumstances, the translation of written mate13 rials; 

14 ‘‘(D) the steps the agency will take to en15 sure that applications, forms, and other rel16 evant documents for its federally conducted pro17 grams and activities are competently translated 

18 into the primary language of a limited-English19 proficient client where such materials are need20 ed to improve access to federally conducted and 

21 federally assisted programs and activities for 

22 such a limited-English-proficient individual; 

23 ‘‘(E) the resources the agency will provide 

24 to improve cultural competence to assist recipi25 ents of Federal funds to improve access to 


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1 health care or health-care-related programs and 

2 activities for limited-English-proficient individ3 uals; 

4 ‘‘(F) the resources the agency will provide 

5 to ensure that competent language assistance is 

6 provided to limited-English-proficient patients 

7 by interpreters or trained bilingual staff; and 

8 ‘‘(G) the resources the agency will provide 

9 to ensure that family, particularly minor chil10 dren, and friends are not used to provide inter11 pretation services, except— 

12 ‘‘(i) in the case of a medical emer13 gency where delay directly associated with 

14 obtaining a competent interpreter would 

15 jeopardize the health of the patient; or 

16 ‘‘(ii) on request of the patient, who 

17 has been informed in his or her preferred 

18 language of the availability of free inter19 pretation services, if the health care serv20 ices provider has determined that the fam21 ily or friend can provide competent inter22 preter services as defined in section 3400. 

23 ‘‘(3) SUBMISSION OF PLAN TO DOJ.—Each 

24 agency that is required to prepare a plan under 

25 paragraph (1) shall send a copy of such plan to the 


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1 Department of Justice, which shall serve as the cen2 tral repository of such plans. 

3 ‘‘(4) RULE OF CONSTRUCTION.—Paragraph 

4 (2)(G)(i) shall not be construed to mean that emer5 gency rooms or similar entities that regularly pro6 vide health care services in medical emergencies are 

7 exempt from legal or regulatory requirements related 

8 to competent interpreter services. 

9 ‘‘(c) FEDERALLY ASSISTED PROGRAMS AND ACTIVI10 TIES.— 

11 ‘‘(1) IN GENERAL.—Not later than 120 days 

12 after the date of enactment of this title, each Fed13 eral agency providing health-care-related Federal fi14 nancial assistance shall ensure that the guidance for 

15 recipients of Federal financial assistance developed 

16 by the agency to ensure compliance with title VI of 

17 the Civil Rights Act of 1964 (42 U.S.C. 2000d et 

18 seq.) is specifically tailored to the recipients of such 

19 assistance. Each agency shall send a copy of such 

20 guidance to the Department of Justice which shall 

21 serve as the central repository of the agency’s plans. 

22 After approval by the Department of Justice, each 

23 agency shall publish its guidance document in the 

24 Federal Register for public comment. 


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1 ‘‘(2) REQUIREMENTS.—The agency-specific 

2 guidance developed under paragraph (1) shall take 

3 into account the types of health care services pro4 vided by the recipients, the individuals served by the 

5 recipients, and other factors set out in such stand6 ards. 

7 ‘‘(3) EXISTING GUIDANCES.—A Federal agency 

8 that has developed a guidance for purposes of title 

9 VI of the Civil Rights Act of 1964 shall examine 

10 such existing guidance, as well as the programs and 

11 activities to which such guidance applies, to deter12 mine if modification of such guidance is necessary to 

13 comply with this subsection. 

14 ‘‘(4) CONSULTATION.—Each Federal agency 

15 shall consult with the Department of Justice in es16 tablishing the guidances under this subsection. 

17 ‘‘(d) CONSULTATIONS.— 

18 ‘‘(1) IN GENERAL.—In carrying out this sec19 tion, each Federal agency that carriers out health 

20 care and health-care-related activities shall ensure 

21 that stakeholders, such as limited-English-proficient 

22 individuals and their representative organizations, 

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1 portunity to provide input with respect to the actions 

2 of the agency. 

3 ‘‘(2) EVALUATION.—Each Federal agency de4 scribed in paragraph (1) shall evaluate the— 

5 ‘‘(A) particular needs of the limited6 English-proficient individuals served by the 

7 agency; 

8 ‘‘(B) particular needs of the limited9 English-proficient individuals served by the 

10 agency’s recipients of Federal financial assist11 ance; and 

12 ‘‘(C) burdens of compliance with the agen13 cy guidance and this section for the agency and 

14 its recipients. 

15 ‘‘SEC. 3402. NATIONAL STANDARDS FOR CULTURALLY AND 

16 LINGUISTICALLY APPROPRIATE SERVICES IN 

17 HEALTH CARE. 

18 ‘‘(a) APPLICABILITY.—This section applies to any 

19 health program or activity, any part of which is receiving 

20 Federal financial assistance, including credits, subsidies, 

21 or contracts of insurance, or any program or activity that 

22 is administered by an executive agency or any entity estab23 lished under title I of the Patient Protection and Afford24 able Care Act (or amendments made thereby), as such 

25 programs, activities, agencies, and entities are described 


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1 in section 1557(a) of the Patient Protection and Afford2 able Care Act. 

3 ‘‘(b) STANDARDS.—The programs, activities, agen4 cies, and entities described in subsection (a)— 

5 ‘‘(1) shall implement strategies to recruit, re6 tain, and promote individuals at all levels to main7 tain a diverse staff and leadership that can provide 

8 culturally and linguistically appropriate health care 

9 to patient populations of the service area of the pro10 grams, activities, agencies, and entities; 

11 ‘‘(2) shall educate and train governance, leader12 ship, and workforce at all levels and across all dis13 ciplines of the programs, activities, agencies, and en14 tities in culturally and linguistically appropriate poli15 cies and practices on an ongoing basis; 

16 ‘‘(3) shall offer and provide language assist17 ance, including trained bilingual staff and inter18 preter services, to individuals who have limited19 English proficiency or other communication needs, 

20 at no cost to them at all points of contact, and dur21 ing all hours of operation, to facilitate timely access 

22 to all health care and services; 

23 ‘‘(4) shall notify patients, in a culturally appro24 priate manner, of their right to receive language asVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 sistance services in their primary language, verbally 

2 and in writing; 

3 ‘‘(5) shall not— 

4 ‘‘(A) require an individual with limited5 English proficiency to provide his or her own 

6 interpreter; 

7 ‘‘(B) rely on an adult accompanying an in8 dividual with limited-English proficiency to in9 terpret or facilitate communication, except— 

10 ‘‘(i) in an emergency involving an im11 minent threat to the safety or welfare of 

12 an individual or the public where there is 

13 no qualified interpreter for the individual 

14 with limited-English proficiency imme15 diately available; or 

16 ‘‘(ii) where the individual with limited17 English proficiency specifically requests 

18 that the accompanying adult interpret or 

19 facilitate communication, the accom20 panying adult agrees to provide such as21 sistance, and reliance on that adult for 

22 such assistance is appropriate under the 

23 circumstances; 

24 ‘‘(C) rely on a minor child to interpret or 

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1 gency involving an imminent threat to the safe2 ty or welfare of an individual or the public 

3 where there is no qualified interpreter for the 

4 individual with limited-English proficiency im5 mediately available; or 

6 ‘‘(D) rely on staff other than qualified bi7 lingual or multilingual staff to communicate di8 rectly with individuals; 

9 ‘‘(6) shall for each eligible LEP language group 

10 that constitutes 5 percent or 500 individuals, which11 ever is less, of the population of persons eligible to 

12 be served or likely to be affected or encountered in 

13 the service area of the organization, make avail14 able— 

15 ‘‘(A) easily understood patient-related ma16 terials, including print and multimedia mate17 rials; 

18 ‘‘(B) information or notices about termi19 nation of benefits; and 

20 ‘‘(C) signage; 

21 ‘‘(7) shall develop and implement clear goals, 

22 policies, operational plans, and management, ac23 countability, and oversight mechanisms to provide 

24 culturally and linguistically appropriate services and 


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1 infuse them throughout the organization’s planning 

2 and operations; 

3 ‘‘(8) shall conduct initial and ongoing organiza4 tional assessments of culturally and linguistically ap5 propriate services-related activities and integrate 

6 valid linguistic, competence-related National Stand7 ards for Culturally and Linguistically Appropriate 

8 Services (CLAS) measures into the internal audits, 

9 performance improvement programs, patient satis10 faction assessments, continuous quality improvement 

11 activities, and outcomes-based evaluations of the or12 ganization and develop ways to standardize the as13 sessments; 

14 ‘‘(9) shall ensure that, consistent with the pri15 vacy protections provided for under the regulations 

16 promulgated under section 264(c) of the Health In17 surance Portability and Accountability Act of 1996, 

18 data on an individual required to be collected pursu19 ant to section 3101, including the individual’s alter20 native format preferences and policy modification 

21 needs, are— 

22 ‘‘(A) collected in health records; 

23 ‘‘(B) integrated into the organization’s 

24 management information systems; and 

25 ‘‘(C) periodically updated; 


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1 ‘‘(10) shall maintain a current demographic, 

2 cultural, and epidemiological profile of the commu3 nity, conduct regular assessments of community 

4 health assets and needs, and use the results to accu5 rately plan for and implement services that respond 

6 to the cultural and linguistic characteristics of the 

7 service area of the organization; 

8 ‘‘(11) shall develop participatory, collaborative 

9 partnerships with communities and utilize a variety 

10 of formal and informal mechanisms to facilitate 

11 community and patient involvement in designing, 

12 implementing, and evaluating policies and practices 

13 to ensure culturally and linguistically appropriate 

14 service-related activities; 

15 ‘‘(12) shall ensure that conflict and grievance 

16 resolution processes are culturally and linguistically 

17 sensitive and capable of identifying, preventing, and 

18 resolving cross-cultural conflicts or complaints by 

19 patients; 

20 ‘‘(13) shall regularly make available to the pub21 lic information about their progress and successful 

22 innovations in implementing the standards under 

23 this section and provide public notice in their com24 munities about the availability of this information; 

25 and 


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1 ‘‘(14) shall, if requested, regularly make avail2 able to the head of each Federal entity from which 

3 Federal funds are received, information about their 

4 progress and successful innovations in implementing 

5 the standards under this section as required by the 

6 head of such entity. 

7 ‘‘SEC. 3403. ROBERT T. MATSUI CENTER FOR CULTURAL 

8 AND LINGUISTIC COMPETENCE IN HEALTH 

9 CARE. 

10 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

11 through the Director of the Agency for Healthcare Re12 search and Quality, shall establish and support a center 

13 to be known as the ‘Robert T. Matsui Center for Cultural 

14 and Linguistic Competence in Health Care’ (referred to 

15 in this section as the ‘Center’) to carry out the following 

16 activities: 

17 ‘‘(1) INTERPRETATION SERVICES.—The Center 

18 shall provide resources via the internet to identify 

19 and link health care providers to competent inter20 preter and translation services. 

21 ‘‘(2) TRANSLATION OF WRITTEN MATERIAL.— 

22 ‘‘(A) The Center shall provide, directly or 

23 through contract, vital documents from com24 petent translation services for providers of 

25 health care and health-care-related services at 


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1 no cost to such providers. Materials may be 

2 submitted for translation into non-English lan3 guages. Translation services shall be provided 

4 in a timely and reasonable manner. The quality 

5 of such translation services shall be monitored 

6 and reported publicly. 

7 ‘‘(B) For each form developed or revised 

8 by the Secretary that will be used by LEP indi9 viduals in health care or health-care-related set10 tings, the Center shall translate the form, at a 

11 minimum, into the top 15 non-English lan12 guages in the United States according to the 

13 most recent data from the American Commu14 nity Survey or its replacement. The translation 

15 must be completed within 45 days of the Sec16 retary receiving final approval of the form from 

17 the Office of Management and Budget. 

18 ‘‘(3) TOLL-FREE CUSTOMER SERVICE TELE19 PHONE NUMBER.—The Center shall provide, 

20 through a toll-free number, a customer service line 

21 for LEP individuals— 

22 ‘‘(A) to obtain information about federally 

23 conducted or funded health programs, including 

24 Medicare, Medicaid, and SCHIP; 


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1 ‘‘(B) to obtain assistance with applying for 

2 or accessing these programs and understanding 

3 Federal notices written in English; and 

4 ‘‘(C) to learn how to access language serv5 ices. 

6 ‘‘(4) HEALTH INFORMATION CLEARING7 HOUSE.— 

8 ‘‘(A) IN GENERAL.—The Center shall de9 velop and maintain an information clearing10 house to facilitate the provision of language 

11 services by providers of health care and health12 care-related services to reduce medical errors, 

13 improve medical outcomes, to improve cultural 

14 competence, reduce health care costs caused by 

15 miscommunication with individuals with lim16 ited-English proficiency, and reduce or elimi17 nate the duplication of effort to translate mate18 rials. The clearinghouse shall make such infor19 mation available on the internet and in print. 

20 Such information shall include the information 

21 described in the succeeding provisions of this 

22 paragraph. 

23 ‘‘(B) DOCUMENT TEMPLATES.—The Cen24 ter shall collect and evaluate for accuracy, de25 velop, and make available templates for standVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00072 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 ard documents that are necessary for patients 

2 and consumers to access and make educated de3 cisions about their health care, including the 

4 following: 

5 ‘‘(i) Administrative and legal docu6 ments, including— 

7 ‘‘(I) intake forms; 

8 ‘‘(II) Medicare, Medicaid, and 

9 SCHIP forms, including eligibility in10 formation; 

11 ‘‘(III) forms informing patient of 

12 HIPAA compliance and consent; and 

13 ‘‘(IV) documents concerning in14 formed consent, advanced directives, 

15 and waivers of rights. 

16 ‘‘(ii) Clinical information, such as how 

17 to take medications, how to prevent trans18 mission of a contagious disease, and other 

19 prevention and treatment instructions. 

20 ‘‘(iii) Public health, patient education, 

21 and outreach materials, such as immuniza22 tion notices, health warnings, or screening 

23 notices. 


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1 ‘‘(iv) Additional health or health-care2 related materials as determined appro3 priate by the Director of the Center. 

4 ‘‘(C) STRUCTURE OF FORMS.—In oper5 ating the clearinghouse, the Center shall— 

6 ‘‘(i) ensure that the documents posted 

7 in English and non-English languages are 

8 culturally appropriate; 

9 ‘‘(ii) allow public review of the docu10 ments before dissemination in order to en11 sure that the documents are understand12 able and culturally appropriate for the tar13 get populations; 

14 ‘‘(iii) allow health care providers to 

15 customize the documents for their use; 

16 ‘‘(iv) facilitate access to these docu17 ments; 

18 ‘‘(v) provide technical assistance with 

19 respect to the access and use of such infor20 mation; and 

21 ‘‘(vi) carry out any other activities the 

22 Secretary determines to be useful to fulfill 

23 the purposes of the clearinghouse. 

24 ‘‘(D) LANGUAGE ASSISTANCE PRO25 GRAMS.—The Center shall provide for the colVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 lection and dissemination of information on cur2 rent examples of language assistance programs 

3 and strategies to improve language services for 

4 LEP individuals, including case studies using 

5 de-identified patient information, program sum6 maries, and program evaluations. 

7 ‘‘(E) CULTURAL AND LINGUISTIC COM8 PETENCE MATERIALS.—The Center shall pro9 vide information relating to culturally and lin10 guistically competent health care for minority 

11 populations residing in the United States to all 

12 health care providers and health-care-related 

13 services at no cost. Such information shall in14 clude— 

15 ‘‘(i) tenets of culturally and linguis16 tically competent care; 

17 ‘‘(ii) cultural and linguistic com18 petence self-assessment tools; 

19 ‘‘(iii) cultural and linguistic com20 petence training tools; 

21 ‘‘(iv) strategic plans to increase cul22 tural and linguistic competence in different 

23 types of providers of health care and 

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1 gional collaborations among health care or2 ganizations; and 

3 ‘‘(v) cultural and linguistic com4 petence information for educators, practi5 tioners, and researchers. 

6 ‘‘(F) INFORMATION ABOUT PROGRESS.— 

7 The Center shall regularly collect and make 

8 publicly available information about the 

9 progress of entities receiving grants under sec10 tion 3404 regarding successful innovations in 

11 implementing the obligations under this sub12 section and provide public notice in the entities’ 

13 communities about the availability of this infor14 mation. 

15 ‘‘(b) DIRECTOR.—The Center shall be headed by a 

16 Director who shall be appointed by, and who shall report 

17 to, the Director of the Agency for Healthcare Research 

18 and Quality. 

19 ‘‘(c) AVAILABILITY OF LANGUAGE ACCESS.—The Di20 rector shall collaborate with the Deputy Assistant Sec21 retary for Minority Health, the Administrator of the Cen22 ters for Medicare & Medicaid Services, and the Adminis23 trator of the Health Resources and Services Administra24 tion to notify health care providers and health care organiVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 zations about the availability of language access services 

2 by the Center. 

3 ‘‘(d) EDUCATION.—The Secretary, directly or 

4 through contract, shall undertake a national education 

5 campaign to inform providers, LEP individuals, health 

6 professionals, graduate schools, and community health 

7 centers about— 

8 ‘‘(1) Federal and State laws and guidelines gov9 erning access to language services; 

10 ‘‘(2) the value of using trained interpreters and 

11 the risks associated with using family members, 

12 friends, minors, and untrained bilingual staff; 

13 ‘‘(3) funding sources for developing and imple14 menting language services; and 

15 ‘‘(4) promising practices to effectively provide 

16 language services. 

17 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—In ad18 dition to the amounts authorized under subsection 

19 (e)(8)(F), there are authorized to be appropriated to carry 

20 out this section $5,000,000 for each of fiscal years 2019 

21 through 2023. 

22 ‘‘SEC. 3404. INNOVATIONS IN CULTURAL AND LINGUISTIC 

23 COMPETENCE GRANTS. 

24 ‘‘(a) IN GENERAL.—The Secretary, acting through 

25 the Director of the Agency for Healthcare Research and 


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1 Quality, shall award grants to eligible entities to enable 

2 such entities to design, implement, and evaluate innova3 tive, cost-effective programs to improve cultural com4 petence and language access in health care for individuals 

5 with limited-English proficiency. The Director of the 

6 Agency for Healthcare Research and Quality shall coordi7 nate with, and ensure the participation of, other agencies 

8 including the Health Resources and Services Administra9 tion, the Center on Minority Health and Health Dispari10 ties at the National Institutes of Health, and the Office 

11 of Minority Health, regarding the design and evaluation 

12 of the grants program. 

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

14 under subsection (a) an entity shall— 

15 ‘‘(1) be— 

16 ‘‘(A) a city, county, Indian Tribe, State, 

17 territory, or subdivision thereof; 

18 ‘‘(B) an organization described in section 

19 501(c)(3) of the Internal Revenue Code of 1986 

20 and exempt from tax under section 501(a) of 

21 such Code; 

22 ‘‘(C) a community health, mental health, 

23 or substance use center or clinic; 

24 ‘‘(D) a solo or group physician practice; 


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1 ‘‘(E) an integrated health care delivery 

2 system; 

3 ‘‘(F) a public hospital; 

4 ‘‘(G) a health care group, university, or 

5 college; or 

6 ‘‘(H) other entity designated by the Sec7 retary; and 

8 ‘‘(2) prepare and submit to the Secretary an 

9 application, at such time, in such manner, and ac10 companied by such additional information as the 

11 Secretary may require. 

12 ‘‘(c) USE OF FUNDS.—An entity shall use funds re13 ceived under a grant under this section to— 

14 ‘‘(1) develop, implement, and evaluate models of 

15 providing competent interpretation services through 

16 onsite interpretation, telephonic interpretation, or 

17 video interpretation; 

18 ‘‘(2) implement strategies to recruit, retain, and 

19 promote individuals at all levels of the organization 

20 to maintain a diverse staff and leadership that can 

21 promote and provide language services to patient 

22 populations of the service area of the organization; 

23 ‘‘(3) develop and maintain a needs assessment 

24 that identifies the current demographic, cultural, 

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1 curately plan for and implement language services 

2 needed in service area of the organization; 

3 ‘‘(4) develop a strategic plan to implement lan4 guage services; 

5 ‘‘(5) develop participatory, collaborative part6 nerships with communities encompassing the LEP 

7 patient populations being served to gain input in de8 signing and implementing language services; 

9 ‘‘(6) develop and implement grievance resolu10 tion processes that are culturally and linguistically 

11 sensitive and capable of identifying, preventing, and 

12 resolving complaints by LEP individuals; 

13 ‘‘(7) develop short-term medical mental health 

14 interpretation training courses and incentives for bi15 lingual health care staff who are asked to interpret 

16 in the workplace; 

17 ‘‘(8) develop formal training programs, includ18 ing continued professional development and edu19 cation programs as well as supervision, for individ20 uals interested in becoming dedicated health care in21 terpreters and culturally competent providers; 

22 ‘‘(9) provide staff language training instruction, 

23 which shall include information on the practical limi24 tations of such instruction for nonnative speakers; 


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1 ‘‘(10) develop policies that address compensa2 tion in salary for staff who receive training to be3 come either a staff interpreter or bilingual provider; 

4 ‘‘(11) develop other language assistance services 

5 as determined appropriate by the Secretary; 

6 ‘‘(12) develop, implement, and evaluate models 

7 of improving cultural competence, including cultural 

8 competence programs for community health workers; 

9 and 

10 ‘‘(13) ensure that, consistent with the privacy 

11 protections provided for under the regulations pro12 mulgated under section 264(c) of the Health Insur13 ance Portability and Accountability Act of 1996 (42 

14 U.S.C. 1320d–2 note) and any applicable State pri15 vacy laws, data on the individual patient or recipi16 ent’s race, ethnicity, and primary language are col17 lected (and periodically updated) in health records 

18 and integrated into the organization’s information 

19 management systems or any similar system used to 

20 store and retrieve data. 

21 ‘‘(d) PRIORITY.—In awarding grants under this sec22 tion, the Secretary shall give priority to entities that pri23 marily engage in providing direct care and that have devel24 oped partnerships with community organizations or with 

25 agencies with experience in improving language access. 


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1 ‘‘(e) EVALUATION.— 

2 ‘‘(1) BY GRANTEES.—An entity that receives a 

3 grant under this section shall submit to the Sec4 retary an evaluation that describes, in the manner 

5 and to the extent required by the Secretary, the ac6 tivities carried out with funds received under the 

7 grant, and how such activities improved access to 

8 health and health-care-related services and the qual9 ity of health care for individuals with limited-English 

10 proficiency. Such evaluation shall be collected and 

11 disseminated through the Robert T. Matsui Center 

12 for Cultural and Linguistic Competence in Health 

13 Care established under section 3403. The Director 

14 of the Agency for Healthcare Research and Quality 

15 shall notify grantees of the availability of technical 

16 assistance for the evaluation and provide such assist17 ance upon request. 

18 ‘‘(2) BY SECRETARY.—The Director of the 

19 Agency for Healthcare Research and Quality shall 

20 evaluate or arrange with other individuals or organi21 zations to evaluate projects funded under this sec22 tion. 

23 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

24 is authorized to be appropriated to carry out this section, 

25 $5,000,000 for each of fiscal years 2019 through 2023. 


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1 ‘‘SEC. 3405. RESEARCH ON CULTURAL AND LANGUAGE COM2 PETENCE. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Director of the Agency for Healthcare Research and 

5 Quality, shall expand research concerning language access 

6 in the provision of health care. 

7 ‘‘(b) ELIGIBILITY.—The Director of the Agency for 

8 Healthcare Research and Quality may conduct the re9 search described in subsection (a) or enter into contracts 

10 with other individuals or organizations to do so. 

11 ‘‘(c) USE OF FUNDS.—Research under this section 

12 shall be designed to do one or more of the following: 

13 ‘‘(1) To identify the barriers to mental and be14 havioral services that are faced by LEP individuals. 

15 ‘‘(2) To identify health care providers’ and 

16 health administrators’ attitudes, knowledge, and 

17 awareness of the barriers to quality health care serv18 ices that are faced by LEP individuals. 

19 ‘‘(3) To identify optimal approaches for deliv20 ering language access. 

21 ‘‘(4) To identify best practices for data collec22 tion, including— 

23 ‘‘(A) the collection by providers of health 

24 care and health-care-related services of data on 

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1 isting research conducted by the Government or 

2 private sector; 

3 ‘‘(B) the development and implementation 

4 of data collection and reporting systems; and 

5 ‘‘(C) effective privacy safeguards for col6 lected data. 

7 ‘‘(5) To develop a minimum data collection set 

8 for primary language. 

9 ‘‘(6) To evaluate the most effective ways in 

10 which the Department can create or coordinate, and 

11 then subsidize or otherwise fund telephonic interpre12 tation providers for health care providers, taking 

13 into consideration, among other factors, the flexi14 bility necessary for such a system to accommodate 

15 variations in— 

16 ‘‘(A) provider type; 

17 ‘‘(B) languages needed and their frequency 

18 of use; 

19 ‘‘(C) type of encounter; 

20 ‘‘(D) time of encounter, including regular 

21 business hours and after hours; and 

22 ‘‘(E) location of encounter. 

23 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

24 are authorized to be appropriated to carry out this section 

25 $5,000,000 for each of fiscal years 2019 through 2023.’’. 


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1 SEC. 203. PILOT PROGRAM FOR IMPROVEMENT AND DE2 VELOPMENT OF STATE MEDICAL INTER3 PRETING SERVICES. 

4 (a) GRANTS AUTHORIZED.—The Secretary shall 

5 award one grant in accordance with this section to each 

6 of three States to assist each such State in designing, im7 plementing, and evaluating a statewide program to provide 

8 onsite interpreter services under Medicaid. 

9 (b) GRANT PERIOD.—A grant awarded under this 

10 section is authorized for a period of three fiscal years be11 ginning on October 1, 2019. 

12 (c) PREFERENCE.—In awarding a grant under this 

13 section, the Secretary shall give preference to a State— 

14 (1) that has a high proportion of qualified LEP 

15 enrollees, as determined by the Secretary; 

16 (2) that has a large number of qualified LEP 

17 enrollees, as determined by the Secretary; 

18 (3) that has a high growth rate of the popu19 lation of LEP individuals, as determined by the Sec20 retary; and 

21 (4) that has a population of qualified LEP en22 rollees that is linguistically diverse, requiring inter23 preter services in at least 200 non-English lan24 guages. 

25 (d) USE OF FUNDS.—A State receiving a grant under 

26 this section shall use the grant funds to— 


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1 (1) ensure that all health care providers in the 

2 State participating in the State plan under Medicaid 

3 have access to onsite interpreter services, for the 

4 purpose of enabling effective communication between 

5 such providers and qualified LEP enrollees during 

6 the furnishing of items and services and administra7 tive interactions; 

8 (2) establish, expand, procure, or contract for— 

9 (A) a statewide health care information 

10 technology system that is designed to achieve 

11 efficiencies and economies of scale with respect 

12 to onsite interpreter services provided to health 

13 care providers in the State participating in the 

14 State plan under Medicaid; and 

15 (B) an entity to administer such system, 

16 the duties of which shall include— 

17 (i) procuring and scheduling inter18 preter services for qualified LEP enrollees; 

19 (ii) procuring and scheduling inter20 preter services for LEP individuals seeking 

21 to enroll in the State plan under Medicaid; 

22 (iii) ensuring that interpreters receive 

23 payment for interpreter services rendered 

24 under the system; and 


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1 (iv) consulting regularly with organi2 zations representing consumers, inter3 preters, and health care providers; and 

4 (3) develop mechanisms to establish, improve, 

5 and strengthen the competency of the medical inter6 pretation workforce that serves qualified LEP enroll7 ees in the State, including a national certification 

8 process that is valid, credible, and vendor-neutral. 

9 (e) APPLICATION.—To receive a grant under this sec10 tion, a State shall submit an application at such time and 

11 containing such information as the Secretary may require, 

12 which shall include the following: 

13 (1) A description of the language access needs 

14 of individuals in the State enrolled in the State plan 

15 under Medicaid. 

16 (2) A description of the extent to which the 

17 program will— 

18 (A) use the grant funds for the purposes 

19 described in subsection (d); 

20 (B) meet the health care needs of rural 

21 populations of the State; and 

22 (C) collect information that accurately 

23 tracks the language services requested by con24 sumers as compared to the language services 


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1 provided by health care providers in the State 

2 participating in the State plan under Medicaid. 

3 (3) A description of how the program will be 

4 evaluated, including a proposal for collaboration with 

5 organizations representing interpreters, consumers, 

6 and LEP individuals. 

7 (f) DEFINITIONS.—In this section: 

8 (1) QUALIFIED LEP ENROLLEE.—The term 

9 ‘‘qualified LEP enrollee’’ means an individual— 

10 (A) who is limited-English proficient; and 

11 (B) who is enrolled in a State plan under 

12 Medicaid. 

13 (2) STATE.—The term ‘‘State’’ has the mean14 ing given the term in section 1101(a)(1) of the So15 cial Security Act (42 U.S.C. 1301(a)(1)), for pur16 poses of title XIX of such Act. 

17 (3) UNITED STATES.—The term ‘‘United 

18 States’’ has the meaning given the term in section 

19 1101(a)(2) of the Social Security Act (42 U.S.C. 

20 1301(a)(2)), for purposes of title XIX of such Act. 

21 (g) FUNDING.— 

22 (1) AUTHORIZATION OF APPROPRIATIONS.— 

23 There is authorized to be appropriated $5,000,000 

24 to carry out this section. 


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1 (2) AVAILABILITY OF FUNDS.—The funds au2 thorized by paragraph (1) shall be available without 

3 fiscal year limitation. 

4 (3) INCREASED FEDERAL FINANCIAL PARTICI5 PATION.—Section 1903(a)(2)(E) of the Social Secu6 rity Act (42 U.S.C. 1396b(a)(2)(E)), as amended by 

7 section 205(d)(1) of this Act, is further amended by 

8 inserting ‘‘(or, in the case of a State receiving a 

9 grant under section 203 of the Health Equity and 

10 Accountability Act of 2018, 100 percent for each 

11 quarter occurring during the grant period)’’ after 

12 ‘‘90 percent’’. 

13 (h) LIMITATION.—No Federal funds under this sec14 tion may be used to provide interpreter services from a 

15 location outside the United States. 

16 SEC. 204. TRAINING TOMORROW’S DOCTORS FOR CUL17 TURALLY AND LINGUISTICALLY APPRO18 PRIATE CARE: GRADUATE MEDICAL EDU19 CATION. 

20 (a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec21 tion 1886(h)(4) of the Social Security Act (42 U.S.C. 

22 1395ww(h)(4)) is amended by adding at the end the fol23 lowing new subparagraph: 

24 ‘‘(L) TREATMENT OF CULTURALLY COM25 PETENCY TRAINING.—In determining a hosVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00089 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 pital’s number of full-time equivalent residents 

2 for purposes of this subsection, all the time that 

3 is spent by an intern or resident in an approved 

4 medical residency training program for edu5 cation and training in cultural competency and 

6 linguistically appropriate service delivery shall 

7 be counted toward the determination of full8 time equivalency.’’. 

9 (b) INDIRECT MEDICAL EDUCATION.—Section 

10 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

11 1395ww(d)(5)(B)) is amended— 

12 (1) by redesignating the clause (x) added by 

13 section 5505(b) of the Patient Protection and Af14 fordable Care Act as clause (xi); and 

15 (2) by adding at the end the following new 

16 clause: 

17 ‘‘(xii) The provisions of subparagraph (L) of 

18 subsection (h)(4) shall apply under this subpara19 graph in the same manner as they apply under such 

20 subsection.’’. 

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

22 subsections (a) and (b) shall apply with respect to pay23 ments made to hospitals on or after the date that is one 

24 year after the date of the enactment of this Act. 


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1 SEC. 205. FEDERAL REIMBURSEMENT FOR CULTURALLY 

2 AND LINGUISTICALLY APPROPRIATE SERV3 ICES UNDER THE MEDICARE, MEDICAID, AND 

4 STATE CHILDREN’S HEALTH INSURANCE 

5 PROGRAMS. 

6 (a) LANGUAGE ACCESS GRANTS FOR MEDICARE

7 PROVIDERS.— 

8 (1) ESTABLISHMENT.— 

9 (A) IN GENERAL.—Not later than 6 

10 months after the date of the enactment of this 

11 Act, the Secretary of Health and Human Serv12 ices, acting through the Centers for Medicare & 

13 Medicaid Services and in consultation with the 

14 Center for Medicare and Medicaid Innovation, 

15 shall establish a demonstration program under 

16 which the Secretary shall award grants to eligi17 ble Medicare service providers to improve com18 munication between such providers and Medi19 care beneficiaries who are English learners, in20 cluding beneficiaries who live in diverse and un21 derserved communities. 

22 (B) APPLICATION OF INNOVATION

23 RULES.—The demonstration project under sub24 paragraph (A) shall be conducted in a manner 

25 that is consistent with the applicable provisions 


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1 of subsections (b), (c), and (d) of section 1115A 

2 of the Social Security Act (42 U.S.C. 1315a). 

3 (C) NUMBER OF GRANTS.—To the extent 

4 practicable, the Secretary shall award not less 

5 than 24 grants under this subsection. 

6 (D) GRANT PERIOD.—Except as provided 

7 under paragraph (2)(D), each grant awarded 

8 under this subsection shall be for a 3-year pe9 riod. 

10 (2) ELIGIBILITY REQUIREMENTS.—To be eligi11 ble for a grant under this subsection, an entity must 

12 meet the following requirements: 

13 (A) MEDICARE PROVIDER.—The entity 

14 must be— 

15 (i) a provider of services under part A 

16 of title XVIII of the Social Security Act; 

17 (ii) a provider of services under part 

18 B of such title; 

19 (iii) a Medicare Advantage organiza20 tion offering a Medicare Advantage plan 

21 under part C of such title; or 

22 (iv) a PDP sponsor offering a pre23 scription drug plan under part D of such 

24 title. 


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1 (B) UNDERSERVED COMMUNITIES.—The 

2 entity must serve a community that, with re3 spect to necessary language services for improv4 ing access and utilization of health care among 

5 English learners, is disproportionally under6 served. 

7 (C) APPLICATION.—The entity must pre8 pare and submit to the Secretary an applica9 tion, at such time, in such manner, and accom10 panied by such additional information as the 

11 Secretary may require. 

12 (D) REPORTING.—In the case of a grantee 

13 that received a grant under this subsection in 

14 a previous year, such grantee is only eligible for 

15 continued payments under a grant under this 

16 subsection if the grantee met the reporting re17 quirements under paragraph (9) for such year. 

18 If a grantee fails to meet the requirement of 

19 such paragraph for the first year of a grant, the 

20 Secretary may terminate the grant and solicit 

21 applications from new grantees to participate in 

22 the demonstration program. 

23 (3) DISTRIBUTION.—To the extent feasible, the 

24 Secretary shall award— 


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1 (A) at least 6 grants to providers of serv2 ices described in paragraph (2)(A)(i); 

3 (B) at least 6 grants to service providers 

4 described in paragraph (2)(A)(ii); 

5 (C) at least 6 grants to organizations de6 scribed in paragraph (2)(A)(iii); and 

7 (D) at least 6 grants to sponsors described 

8 in paragraph (2)(A)(iv). 

9 (4) CONSIDERATIONS IN AWARDING GRANTS.— 

10 (A) VARIATION IN GRANTEES.—In award11 ing grants under this subsection, the Secretary 

12 shall select grantees to ensure the following: 

13 (i) The grantees provide many dif14 ferent types of language services. 

15 (ii) The grantees serve Medicare bene16 ficiaries who speak different languages, 

17 and who, as a population, have differing 

18 needs for language services. 

19 (iii) The grantees serve Medicare 

20 beneficiaries in both urban and rural set21 tings. 

22 (iv) The grantees serve Medicare 

23 beneficiaries in at least two geographic re24 gions, as defined by the Secretary. 


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1 (v) The grantees serve Medicare bene2 ficiaries in at least two large metropolitan 

3 statistical areas with racial, ethnic, sexual, 

4 gender, disability, and economically diverse 

5 populations. 

6 (B) PRIORITY FOR PARTNERSHIPS WITH

7 COMMUNITY ORGANIZATIONS AND AGENCIES.— 

8 In awarding grants under this subsection, the 

9 Secretary shall give priority to eligible entities 

10 that have a partnership with— 

11 (i) a community organization; or 

12 (ii) a consortia of community organi13 zations, State agencies, and local agencies, 

14 that has experience in providing language serv15 ices. 

16 (5) USE OF FUNDS FOR COMPETENT LANGUAGE

17 SERVICES.— 

18 (A) IN GENERAL.—Subject to subpara19 graph (E), a grantee may only use grant funds 

20 received under this subsection to pay for the 

21 provision of competent language services to 

22 Medicare beneficiaries who are English learn23 ers. 


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1 (B) COMPETENT LANGUAGE SERVICES DE2 FINED.—For purposes of this subsection, the 

3 term ‘‘competent language services’’ means— 

4 (i) interpreter and translation services 

5 that— 

6 (I) subject to the exceptions 

7 under subparagraph (C)— 

8 (aa) if the grantee operates 

9 in a State that has statewide 

10 health care interpreter standards, 

11 meet the State standards cur12 rently in effect; or 

13 (bb) if the grantee operates 

14 in a State that does not have 

15 statewide health care interpreter 

16 standards, utilizes competent in17 terpreters who follow the Na18 tional Council on Interpreting in 

19 Health Care’s Code of Ethics and 

20 Standards of Practice; and 

21 (II) that, in the case of inter22 preter services, are provided 

23 through— 

24 (aa) onsite interpretation; 


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1 (bb) telephonic interpreta2 tion; or 

3 (cc) video interpretation; 

4 and 

5 (ii) the direct provision of health care 

6 or health-care-related services by a com7 petent bilingual health care provider. 

8 (C) EXCEPTIONS.—The requirements of 

9 subparagraph (B)(i)(I) do not apply, with re10 spect to interpreter and translation services and 

11 a grantee— 

12 (i) in the case of a Medicare bene13 ficiary who is an English learner if— 

14 (I) such beneficiary has been in15 formed, in the beneficiary’s primary 

16 language, of the availability of free in17 terpreter and translation services and 

18 the beneficiary instead requests that a 

19 family member, friend, or other per20 son provide such services; and 

21 (II) the grantee documents such 

22 request in the beneficiary’s medical 

23 record; or 

24 (ii) in the case of a medical emergency 

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1 taining a competent interpreter or trans2 lation services would jeopardize the health 

3 of the patient. 

4 Clause (ii) shall not be construed to exempt 

5 emergency rooms or similar entities that regu6 larly provide health care services in medical 

7 emergencies to patients who are English learn8 ers from any applicable legal or regulatory re9 quirements related to providing competent in10 terpreter and translation services without undue 

11 delay. 

12 (D) MEDICARE ADVANTAGE ORGANIZA13 TIONS AND PDP SPONSORS.—If a grantee is a 

14 Medicare Advantage organization offering a 

15 Medicare Advantage plan under part C of title 

16 XVIII of the Social Security Act or a PDP 

17 sponsor offering a prescription drug plan under 

18 part D of such title, such entity must provide 

19 at least 50 percent of the grant funds that the 

20 entity receives under this subsection directly to 

21 the entity’s network providers (including all 

22 health providers and pharmacists) for the pur23 pose of providing support for such providers to 

24 provide competent language services to Medi25 care beneficiaries who are English learners. 


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1 (E) ADMINISTRATIVE AND REPORTING

2 COSTS.—A grantee may use up to 10 percent of 

3 the grant funds to pay for administrative costs 

4 associated with the provision of competent lan5 guage services and for reporting required under 

6 paragraph (9). 

7 (6) DETERMINATION OF AMOUNT OF GRANT

8 PAYMENTS.— 

9 (A) IN GENERAL.—Payments to grantees 

10 under this subsection shall be calculated based 

11 on the estimated numbers of Medicare bene12 ficiaries who are English learners in a grantee’s 

13 service area utilizing— 

14 (i) data on the numbers of English 

15 learners who speak English less than ‘‘very 

16 well’’ from the most recently available data 

17 from the Bureau of the Census or other 

18 State-based study the Secretary determines 

19 likely to yield accurate data regarding the 

20 number of such individuals in such service 

21 area; or 

22 (ii) data provided by the grantee, if 

23 the grantee routinely collects data on the 

24 primary language of the Medicare bene25 ficiaries that the grantee serves and the 


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1 Secretary determines that the data is accu2 rate and shows a greater number of 

3 English learners than would be estimated 

4 using the data under clause (i). 

5 (B) DISCRETION OF SECRETARY.—Subject 

6 to subparagraph (C), the amount of payment 

7 made to a grantee under this subsection may be 

8 modified annually at the discretion of the Sec9 retary, based on changes in the data under sub10 paragraph (A) with respect to the service area 

11 of a grantee for the year. 

12 (C) LIMITATION ON AMOUNT.—The 

13 amount of a grant made under this subsection 

14 to a grantee may not exceed $500,000 for the 

15 period under paragraph (1)(D). 

16 (7) ASSURANCES.—Grantees under this sub17 section shall, as a condition of receiving a grant 

18 under this subsection— 

19 (A) ensure that clinical and support staff 

20 receive appropriate ongoing education and 

21 training in linguistically appropriate service de22 livery; 

23 (B) ensure the linguistic competence of bi24 lingual providers; 


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1 (C) offer and provide appropriate language 

2 services at no additional charge to each patient 

3 who is an English learner for all points of con4 tact between the patient and the grantee, in a 

5 timely manner during all hours of operation; 

6 (D) notify Medicare beneficiaries of their 

7 right to receive language services in their pri8 mary language; 

9 (E) post signage in the primary languages 

10 commonly used by the patient population in the 

11 service area of the organization; and 

12 (F) ensure that— 

13 (i) primary language data are col14 lected for recipients of language services 

15 and such data are consistent with stand16 ards developed under title XXXIV of the 

17 Public Health Service Act, as added by 

18 section 202 of this Act, to the extent such 

19 standards are available upon the initiation 

20 of the demonstration program; and 

21 (ii) consistent with the privacy protec22 tions provided under the regulations pro23 mulgated pursuant to section 264(c) of the 

24 Health Insurance Portability and Account25 ability Act of 1996 (42 U.S.C. 1320d–2 


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1 note), if the recipient of language services 

2 is a minor or is incapacitated, primary lan3 guage data are collected on the parent or 

4 legal guardian of such recipient. 

5 (8) NO COST SHARING.—Medicare beneficiaries 

6 who are English learners shall not have to pay cost 

7 sharing or co-payments for competent language serv8 ices provided under this demonstration program. 

9 (9) REPORTING REQUIREMENTS FOR GRANT10 EES.—Not later than the end of each calendar year, 

11 a grantee that receives funds under this subsection 

12 in such year shall submit to the Secretary a report 

13 that includes the following information: 

14 (A) The number of Medicare beneficiaries 

15 to whom competent language services are pro16 vided. 

17 (B) The primary languages of those Medi18 care beneficiaries. 

19 (C) The types of language services pro20 vided to such beneficiaries. 

21 (D) Whether such language services were 

22 provided by employees of the grantee or 

23 through a contract with external contractors or 

24 agencies. 


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1 (E) The types of interpretation services 

2 provided to such beneficiaries, and the approxi3 mate length of time such service is provided to 

4 such beneficiaries. 

5 (F) The costs of providing competent lan6 guage services. 

7 (G) An account of the training or accredi8 tation of bilingual staff, interpreters, and trans9 lators providing services funded by the grant 

10 under this subsection. 

11 (10) EVALUATION AND REPORT TO CON12 GRESS.—Not later than 1 year after the completion 

13 of a 3-year grant under this subsection, the Sec14 retary shall conduct an evaluation of the demonstra15 tion program under this subsection and shall submit 

16 to the Congress a report that includes the following: 

17 (A) An analysis of the patient outcomes 

18 and the costs of furnishing care to the Medicare 

19 beneficiaries who are English learners partici20 pating in the project as compared to such out21 comes and costs for such Medicare beneficiaries 

22 not participating, based on the data provided 

23 under paragraph (9) and any other information 

24 available to the Secretary. 


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1 (B) The effect of delivering language serv2 ices on— 

3 (i) Medicare beneficiary access to care 

4 and utilization of services; 

5 (ii) the efficiency and cost effective6 ness of health care delivery; 

7 (iii) patient satisfaction; 

8 (iv) health outcomes; and 

9 (v) the provision of culturally appro10 priate services provided to such bene11 ficiaries. 

12 (C) The extent to which bilingual staff, in13 terpreters, and translators providing services 

14 under such demonstration were trained or ac15 credited and the nature of accreditation or 

16 training needed by type of provider, service, or 

17 other category as determined by the Secretary 

18 to ensure the provision of high-quality interpre19 tation, translation, or other language services to 

20 Medicare beneficiaries if such services are ex21 panded pursuant to subsection (c) of section 

22 1907 of this Act. 

23 (D) Recommendations, if any, regarding 

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1 tion 1115A(c) of the Social Security Act (42 

2 U.S.C. 1315a(c)). 

3 (11) APPROPRIATIONS.—There is appropriated 

4 to carry out this subsection, in equal parts from the 

5 Federal Hospital Insurance Trust Fund under sec6 tion 1817 of the Social Security Act (42 U.S.C. 

7 1395i) and the Federal Supplementary Medical In8 surance Trust Fund under section 1841 of such Act 

9 (42 U.S.C. 1395t), $16,000,000 for each fiscal year 

10 of the demonstration program. 

11 (12) ENGLISH LEARNER DEFINED.—In this 

12 subsection, the term ‘‘English learner’’ has the 

13 meaning given such term in section 8101(20) of the 

14 Elementary and Secondary Education Act of 1965, 

15 except that subparagraphs (A), (B), and (D) of such 

16 section shall not apply. 

17 (b) LANGUAGE SERVICES UNDER THE MEDICARE

18 PROGRAM.— 

19 (1) INCLUSION AS RURAL HEALTH CLINIC

20 SERVICES.—Section 1861 of the Social Security Act 

21 (42 U.S.C. 1395x) is amended— 

22 (A) in subsection (aa)(1)— 

23 (i) in subparagraph (B), by striking 

24 ‘‘and’’ at the end; 


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1 (ii) by adding ‘‘and’’ at the end of 

2 subparagraph (C); and 

3 (iii) by inserting after subparagraph 

4 (C) the following new subparagraph: 

5 ‘‘(D) language assistance services as defined in 

6 subsection (iii)(1),’’; and 

7 (B) by adding at the end the following new 

8 subsection: 

9 ‘‘Language Assistance Services and Related Terms 

10 ‘‘(iii)(1) The term ‘language assistance services’ has 

11 the same meaning given the term ‘language or language 

12 assistance services’ in section 3400 of the Public Health 

13 Service Act. 

14 ‘‘(2) The term ‘interpreter services’ has the meaning 

15 given the term ‘qualified interpreter for an individual with 

16 limited-English proficiency’ in section 3400(3) of the Pub17 lic Health Service Act. 

18 ‘‘(3) The term ‘qualified interpreter for an individual 

19 with limited-English proficiency’ means an interpreter who 

20 via a remote interpreting service or an onsite appear21 ance— 

22 ‘‘(A) adheres to generally accepted interpreter 

23 ethics principles, including client confidentiality; 


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1 ‘‘(B) has demonstrated proficiency in speaking 

2 and understanding both spoken English and at least 

3 one other spoken language; and 

4 ‘‘(C) is able to interpret effectively, accurately, 

5 and impartially and in a culturally competent man6 ner, both receptively and expressly, to and from such 

7 language(s) and English, using any necessary spe8 cialized vocabulary, terminology, and phraseology. 

9 ‘‘(4) The term ‘qualified translator’ means a trans10 lator who— 

11 ‘‘(A) adheres to generally accepted translator 

12 ethics principles, including client confidentiality; 

13 ‘‘(B) has demonstrated proficiency in writing 

14 and understanding both written English and at least 

15 one other written non-English language; and 

16 ‘‘(C) is able to translate effectively, accurately, 

17 and impartially to and from such language(s) and 

18 English, using any necessary specialized vocabulary, 

19 terminology, and phraseology. 

20 ‘‘(5) The term ‘English learner’ has the meaning 

21 given such term in section 8101(20) of the Elementary 

22 and Secondary Education Act of 1965, except that sub23 paragraphs (A), (B), and (D) of such section shall not 

24 apply.’’. 


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1 (2) COVERAGE.—Section 1832(a)(2) of the So2 cial Security Act (42 U.S.C. 1395k(a)(2)) is amend3 ed— 

4 (A) by striking ‘‘and’’ at the end of sub5 paragraph (I); 

6 (B) by striking the period at the end of 

7 subparagraph (J) and inserting ‘‘; and’’; and 

8 (C) by adding at the end the following new 

9 subparagraph: 

10 ‘‘(K) language services (as defined in para11 graph (1) of section 1861(iii)) furnished by an 

12 interpreter (as defined in paragraph (3) of such 

13 section) or translator.’’. 

14 (3) PAYMENT.—Section 1833(a) of the Social 

15 Security Act (42 U.S.C. 1395l(a)) is amended— 

16 (A) by striking ‘‘and’’ at the end of para17 graph (8); 

18 (B) by striking the period at the end of 

19 paragraph (9) and inserting ‘‘; and’’; and 

20 (C) by inserting after paragraph (9) the 

21 following new paragraph: 

22 ‘‘(10) in the case of language services described 

23 in section 1861(iii)(1), 100 percent of the reasonable 

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1 tion with the Medicare Payment Advisory Commis2 sion; and’’. 

3 (4) WAIVER OF BUDGET NEUTRALITY.—For 

4 the 3-year period beginning on the date of enact5 ment of this section, the budget neutrality provision 

6 of section 1848(c)(2)(B)(ii) of the Social Security 

7 Act (42 U.S.C. 1395w–4(c)(2)(B)(ii)) shall not 

8 apply with respect to language services (as such 

9 term is defined in section 1861(iii)(1) of such Act). 

10 (c) MEDICARE PARTS C AND D.— 

11 (1) IN GENERAL.—Medicare Advantage plans 

12 under part C of the Social Security Act and pre13 scription drug plans under part D of such Act shall 

14 comply with title VI of the Civil Rights Act of 1964 

15 and section 1557 of the Patient Protection and Af16 fordable Care Act (42 U.S.C. 18116) to provide ef17 fective language services to enrollees of such plans. 

18 (2) MEDICARE ADVANTAGE PLANS AND PRE19 SCRIPTION DRUG PLANS REPORTING REQUIRE20 MENT.—Section 1857(e) of the Social Security Act 

21 (42 U.S.C. 1395w–27(e)) is amended by adding at 

22 the end the following new paragraph: 

23 ‘‘(5) REPORTING REQUIREMENTS RELATING TO

24 EFFECTIVE LANGUAGE SERVICES.—A contract under 

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1 zation (and, through application of section 1860D– 

2 12(b)(3)(D), a contract under section 1860D–12 

3 shall require a PDP sponsor) to annually submit 

4 (for each year of the contract) a report that contains 

5 information on the plan’s internal policies and proce6 dures related to recruitment and retention efforts di7 rected to workforce diversity and linguistically and 

8 culturally appropriate provision of services in each of 

9 the following contexts: 

10 ‘‘(A) The collection of data in a manner 

11 that meets the requirements of title I of the 

12 Health Equity and Accountability Act of 2018, 

13 regarding the enrollee population. 

14 ‘‘(B) Education of staff and contractors 

15 who have routine contact with enrollees regard16 ing the various needs of the diverse enrollee 

17 population. 

18 ‘‘(C) Evaluation of the health plan’s lan19 guage services programs and services with re20 spect to the plan’s enrollee population, such as 

21 through analysis of complaints or satisfaction 

22 survey results. 

23 ‘‘(D) Methods by which the plan provides 

24 to the Secretary information regarding the eth25 nic diversity of the plan’s enrollee population. 


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1 ‘‘(E) The periodic provision of educational 

2 information to plan enrollees on the plan’s lan3 guage services and programs.’’. 

4 (d) IMPROVING LANGUAGE SERVICES IN MEDICAID

5 AND CHIP.— 

6 (1) PAYMENTS TO STATES.—Section 

7 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 

8 1396b(a)(2)(E)) is amended by— 

9 (A) striking ‘‘75’’ and inserting ‘‘90’’; 

10 (B) striking ‘‘translation or interpretation 

11 services’’ and inserting ‘‘language services’’; 

12 and 

13 (C) striking ‘‘children of families’’ and in14 serting ‘‘individuals’’. 

15 (2) STATE PLAN REQUIREMENTS.—Section 

16 1902(a)(10)(A) of the Social Security Act (42 

17 U.S.C. 1396a(a)(10)(A)) is amended by striking 

18 ‘‘and (28)’’ and inserting ‘‘(28), and (29)’’. 

19 (3) DEFINITION OF MEDICAL ASSISTANCE.— 

20 Section 1905(a) of the Social Security Act (42 

21 U.S.C. 1396d(a)) is amended by— 

22 (A) in paragraph (28), by striking ‘‘and’’ 

23 at the end; 

24 (B) by redesignating paragraph (29) as 

25 paragraph (30); and 


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1 (C) by inserting after paragraph (28) the 

2 following new paragraph: 

3 ‘‘(29) language services, as such term is defined 

4 in section 1861(iii)(1), provided in a timely manner 

5 to English learners (as defined in section 

6 1861(iii)(5)) who need such services; and’’. 

7 (4) USE OF DEDUCTIONS AND COST SHAR8 ING.—Section 1916(a)(2) of the Social Security Act 

9 (42 U.S.C. 1396o(2)) is amended by— 

10 (A) by striking ‘‘or’’ at the end of subpara11 graph (D); 

12 (B) by striking ‘‘; and’’ at the end of sub13 paragraph (E) and inserting ‘‘, or’’; and 

14 (C) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(F) language services described in section 

17 1905(a)(29); and’’. 

18 (5) CHIP COVERAGE REQUIREMENTS.—Section 

19 2103 of the Social Security Act (42 U.S.C. 1397cc) 

20 is amended— 

21 (A) in subsection (a), in the matter before 

22 paragraph (1), by striking ‘‘and (7)’’ and in23 serting ‘‘(7), and (9)’’; and 

24 (B) in subsection (c), by adding at the end 

25 the following new paragraph: 


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1 ‘‘(9) LANGUAGE SERVICES.—The child health 

2 assistance provided to a targeted low-income child 

3 shall include coverage of language services, as such 

4 term is defined in section 1861(iii)(1), provided in a 

5 timely manner to English learners (as defined in 

6 section 1861(iii)(5)) who need such services.’’; and 

7 (C) in subsection (e)(2)— 

8 (i) in the heading, by striking ‘‘PRE9 VENTIVE’’ and inserting ‘‘CERTAIN’’; and 

10 (ii) by inserting ‘‘or subsection (c)(9)’’ 

11 after ‘‘subsection (c)(1)(D)’’. 

12 (6) DEFINITION OF CHILD HEALTH ASSIST13 ANCE.—Section 2110(a)(27) of the Social Security 

14 Act (42 U.S.C. 1397jj) is amended by striking 

15 ‘‘translation’’ and inserting ‘‘language services as 

16 described in section 2103(c)(9)’’. 

17 (7) STATE DATA COLLECTION.—Pursuant to 

18 the reporting requirement described in section 

19 2107(b)(1) of the Social Security Act (42 U.S.C. 

20 1397gg(b)(1)), the Secretary of Health and Human 

21 Services shall require that States collect data on— 

22 (A) the primary language of individuals re23 ceiving child health assistance under title XXI 

24 of the Social Security Act; and 


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1 (B) in the case of such individuals who are 

2 minors or incapacitated, the primary language 

3 of the individual’s parent or guardian. 

4 (8) CHIP PAYMENTS TO STATES.—Section 

5 2105 of the Social Security Act (42 U.S.C. 

6 1397ee(c)) is amended— 

7 (A) in subsection (a)(1), by striking ‘‘75’’ 

8 and inserting ‘‘90’’; and 

9 (B) in subsection (c)(2)(A), by inserting 

10 before the period at the end the following: ‘‘, 

11 except that expenditures pursuant to clause (iv) 

12 of subparagraph (D) of such paragraph shall 

13 not count towards this total’’. 

14 (e) FUNDING LANGUAGE SERVICES FURNISHED BY

15 PROVIDERS OF HEALTH CARE AND HEALTH-CARE-RE16 LATED SERVICES THAT SERVE HIGH RATES OF UNIN17 SURED LEP INDIVIDUALS.— 

18 (1) PAYMENT OF COSTS.— 

19 (A) IN GENERAL.—Subject to subpara20 graph (B), the Secretary of Health and Human 

21 Services shall make payments (on a quarterly 

22 basis) directly to eligible entities to support the 

23 provision of language services to English learn24 ers in an amount equal to an eligible entity’s el25 igible costs for such services for the quarter. 


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1 (B) FUNDING.—Out of any funds in the 

2 Treasury not otherwise appropriated, there are 

3 appropriated to the Secretary of Health and 

4 Human Services such sums as may be nec5 essary for each of fiscal years 2017 through 

6 2021. 

7 (C) RELATION TO MEDICAID DSH.—Pay8 ments under this subsection shall not offset or 

9 reduce payments under section 1923 of the So10 cial Security Act, nor shall payments under 

11 such section be considered when determining 

12 uncompensated costs associated with the provi13 sion of language services. 

14 (2) METHODOLOGY FOR PAYMENT OF

15 CLAIMS.— 

16 (A) IN GENERAL.—The Secretary shall es17 tablish a methodology to determine the average 

18 per person cost of language services. 

19 (B) DIFFERENT ENTITIES.—In estab20 lishing such methodology, the Secretary may es21 tablish different methodologies for different 

22 types of eligible entities. 

23 (C) NO INDIVIDUAL CLAIMS.—The Sec24 retary may not require eligible entities to sub25 mit individual claims for language services for 


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1 individual patients as a requirement for pay2 ment under this subsection. 

3 (3) DATA COLLECTION INSTRUMENT.—For pur4 poses of this subsection, the Secretary shall create a 

5 standard data collection instrument that is con6 sistent with any existing reporting requirements by 

7 the Secretary or relevant accrediting organizations 

8 regarding the number of individuals to whom lan9 guage access are provided. 

10 (4) GUIDELINES.—Not later than 6 months 

11 after the date of enactment of this Act, the Sec12 retary of Health and Human Services shall establish 

13 and distribute guidelines concerning the implementa14 tion of this subsection. 

15 (5) REPORTING REQUIREMENTS.— 

16 (A) REPORT TO SECRETARY.—Entities re17 ceiving payment under this subsection shall pro18 vide the Secretary with a quarterly report on 

19 how the entity used such funds. Such report 

20 shall contain aggregate (and may not contain 

21 individualized) data collected using the instru22 ment under paragraph (3) and shall otherwise 

23 be in a form and manner determined by the 

24 Secretary. 


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1 (B) REPORT TO CONGRESS.—Not later 

2 than 2 years after the date of enactment of this 

3 Act, and every 2 years thereafter, the Secretary 

4 shall submit a report to Congress concerning 

5 the implementation of this subsection. 

6 (6) DEFINITIONS.—In this subsection: 

7 (A) ELIGIBLE COSTS.—The term ‘‘eligible 

8 costs’’ means, with respect to an eligible entity 

9 that provides language services to English 

10 learners, the product of— 

11 (i) the average per person cost of lan12 guage services, determined according to 

13 the methodology devised under paragraph 

14 (2); and 

15 (ii) the number of English learners 

16 who are provided language services by the 

17 entity and for whom no reimbursement is 

18 available for such services under the 

19 amendments made by subsections (a), (b), 

20 (c), or (d) or by private health insurance. 

21 (B) ELIGIBLE ENTITY.—The term ‘‘eligible 

22 entity’’ means an entity that— 

23 (i) is a Medicaid provider that is— 

24 (I) a physician; 


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1 (II) a hospital with a low-income 

2 utilization rate (as defined in section 

3 1923(b)(3) of the Social Security Act 

4 (42 U.S.C. 1396r–4(b)(3))) of greater 

5 than 25 percent; or 

6 (III) a federally qualified health 

7 center (as defined in section 

8 1905(l)(2)(B) of the Social Security 

9 Act (42 U.S.C. 1396d(l)(2)(B))); 

10 (ii) provide language services to at 

11 least 8 percent of the entity’s total number 

12 of patients, not later than 6 months after 

13 the date of the enactment of the Act; and 

14 (iii) prepare and submit an applica15 tion to the Secretary, at such time, in such 

16 manner, and accompanied by such infor17 mation as the Secretary may require to as18 certain the entity’s eligibility for funding 

19 under this subsection. 

20 (C) ENGLISH LEARNER.—The term 

21 ‘‘English learner’’ has the meaning given such 

22 term in section 8101(20) of the Elementary 

23 and Secondary Education Act of 1965, except 

24 that subparagraphs (A), (B), and (D) of such 

25 section shall not apply. 


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1 (D) LANGUAGE SERVICES.—The term 

2 ‘‘language services’’ has the meaning given such 

3 term in section 1861(iii)(1) of the Social Secu4 rity Act. 

5 (f) APPLICATION OF CIVIL RIGHTS ACT OF 1964 AND

6 OTHER LAWS.—Nothing in this section shall be construed 

7 to limit otherwise existing obligations of recipients of Fed8 eral financial assistance under title VI of the Civil Rights 

9 Act of 1964 (42 U.S.C. 2000(d) et seq.) or other laws 

10 that protect the civil rights of individuals. 

11 (g) EFFECTIVE DATE.— 

12 (1) IN GENERAL.—Except as otherwise pro13 vided and subject to paragraph (2), the amendments 

14 made by this section shall take effect on January 1, 

15 2017. 

16 (2) EXCEPTION IF STATE LEGISLATION RE17 QUIRED.—In the case of a State plan for medical as18 sistance under title XIX of the Social Security Act 

19 which the Secretary of Health and Human Services 

20 determines requires State legislation (other than leg21 islation appropriating funds) in order for the plan to 

22 meet the additional requirement imposed by the 

23 amendments made by this section, the State plan 

24 shall not be regarded as failing to comply with the 

25 requirements of such title solely on the basis of its 


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1 failure to meet this additional requirement before 

2 the first day of the first calendar quarter beginning 

3 after the close of the first regular session of the 

4 State legislature that begins after the date of the en5 actment of this Act. For purposes of the previous 

6 sentence, in the case of a State that has a 2-year 

7 legislative session, each year of such session shall be 

8 deemed to be a separate regular session of the State 

9 legislature. 

10 SEC. 206. INCREASING UNDERSTANDING OF AND IMPROV11 ING HEALTH LITERACY. 

12 (a) IN GENERAL.—The Secretary, acting through the 

13 Director of the Agency for Healthcare Research and Qual14 ity and the Administrator of the Health Resources and 

15 Services Administration, in consultation with the Director 

16 of the National Institute on Minority Health and Health 

17 Disparities and the Deputy Assistant Secretary for Minor18 ity Health, shall award grants to eligible entities to im19 prove health care for patient populations that have low 

20 functional health literacy. 

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

22 under subsection (a), an entity shall— 

23 (1) be a hospital, health center or clinic, health 

24 plan, or other health entity (including a nonprofit 

25 minority health organization or association); and 


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1 (2) prepare and submit to the Secretary an ap2 plication at such time, in such manner, and con3 taining such information as the Secretary may re4 quire. 

5 (c) USE OF FUNDS.— 

6 (1) AGENCY FOR HEALTHCARE RESEARCH AND

7 QUALITY.—Grants awarded under subsection (a) 

8 through the Agency for Healthcare Research and 

9 Quality shall be used— 

10 (A) to define and increase the under11 standing of health literacy; 

12 (B) to investigate the correlation between 

13 low health literacy and health and health care; 

14 (C) to clarify which aspects of health lit15 eracy have an effect on health outcomes; and 

16 (D) for any other activity determined ap17 propriate by the Director of the Agency. 

18 (2) HEALTH RESOURCES AND SERVICES ADMIN19 ISTRATION.—Grants awarded under subsection (a) 

20 through the Health Resources and Services Adminis21 tration shall be used to conduct demonstration 

22 projects for interventions for patients with low 

23 health literacy that may include— 


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1 (A) the development of new disease man2 agement programs for patients with low health 

3 literacy; 

4 (B) the tailoring of existing disease man5 agement programs addressing mental, physical, 

6 oral, and behavioral health conditions for pa7 tients with low health literacy; 

8 (C) the translation of written health mate9 rials for patients with low health literacy; 

10 (D) the identification, implementation, and 

11 testing of low health literacy screening tools; 

12 (E) the conduct of educational campaigns 

13 for patients and providers about low health lit14 eracy; and 

15 (F) other activities determined appropriate 

16 by the Administrator of the Health Resources 

17 and Services Administration. 

18 (d) DEFINITIONS.—In this section, the term ‘‘low 

19 health literacy’’ means the inability of an individual to ob20 tain, process, and understand basic health information 

21 and services needed to make appropriate health decisions. 

22 (e) AUTHORIZATION OF APPROPRIATIONS.—There 

23 are authorized to be appropriated to carry out this section, 

24 such sums as may be necessary for each of fiscal years 

25 2019 through 2023. 


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1 SEC. 207. ASSURANCES FOR RECEIVING FEDERAL FUNDS. 

2 (a) IN GENERAL.—Any health program or activity, 

3 any part of which is receiving Federal financial assistance, 

4 including credits, subsidies, or contracts of insurance, and 

5 any program or activity that is administered by an execu6 tive agency or any entity established under title I of the 

7 Patient Protection and Affordable Care Act (or amend8 ments made thereby), as such programs, activities, agen9 cies, and entities are described in section 1557(a) of the 

10 Patient Protection and Affordable Care Act (42 U.S.C. 

11 18116), in order to ensure the right of LEP individuals 

12 to receive access to quality health care, shall— 

13 (1) ensure that appropriate clinical and support 

14 staff receive ongoing education and training in lin15 guistically appropriate service delivery; 

16 (2) offer and provide appropriate language as17 sistance services at no additional charge to each pa18 tient with limited-English-proficiency at all points of 

19 contact, in a timely manner during all hours of oper20 ation; 

21 (3) notify patients of their right to receive lan22 guage services in their primary language; and 

23 (4) utilize only qualified interpreters for an in24 dividual with limited-English proficiency or qualified 

25 translators, as defined in section 3400 of the Public 

26 Health Service Act. 


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1 (b) EXEMPTIONS.—The requirements of subsection 

2 (a)(4) shall not apply as follows: 

3 (1) When a patient (who has been informed in 

4 his or her primary language of the availability of 

5 free interpreter and translation services) requests 

6 the use of family, friends, or other persons untrained 

7 in interpretation or translation if the following con8 ditions are met: 

9 (A) The interpreter requested by the pa10 tient is over the age of 18. 

11 (B) The recipient informs the patient that 

12 he or she has the option of having the recipient 

13 provide an interpreter for him or her without 

14 charge, or of using his or her own interpreter. 

15 (C) The recipient informs the patient that 

16 the recipient may not require an LEP person to 

17 use a family member or friend as an inter18 preter. 

19 (D) The recipient evaluates whether the 

20 person the patient wishes to use as an inter21 preter is competent. If the recipient has reason 

22 to believe that the interpreter is not competent, 

23 the recipient provides the recipient’s own inter24 preter to protect the recipient from liability if 


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1 the patient’s interpreter is later found not com2 petent. 

3 (E) If the recipient has reason to believe 

4 that there is a conflict of interest between the 

5 interpreter and patient, the recipient may not 

6 use the patient’s interpreter. 

7 (F) The recipient has the patient sign a 

8 waiver, witnessed by at least 1 individual not 

9 related to the patient, that includes the infor10 mation stated in subparagraphs (A) through 

11 (E) and is translated into the patient’s lan12 guage. 

13 (2) When a medical emergency exists and the 

14 delay directly associated with obtaining competent 

15 interpreter or translation services would jeopardize 

16 the health of the patient, but only until a competent 

17 interpreter or translation service is available. 

18 (c) RULE OF CONSTRUCTION.—Subsection (b)(2) 

19 shall not be construed to mean that emergency rooms or 

20 similar entities that regularly provide health care services 

21 in medical emergencies are exempt from legal or regu22 latory requirements related to competent interpreter serv23 ices. 


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1 SEC. 208. REPORT ON FEDERAL EFFORTS TO PROVIDE CUL2 TURALLY AND LINGUISTICALLY APPRO3 PRIATE HEALTH CARE SERVICES. 

4 (a) REPORT.—Not later than 1 year after the date 

5 of enactment of this Act and annually thereafter, the Sec6 retary of Health and Human Services shall enter into a 

7 contract with the National Academy of Medicine for the 

8 preparation and publication of a report that describes 

9 Federal efforts to ensure that all individuals with limited10 English proficiency have meaningful access culturally com11 petent to health care and health-care-related services. 

12 Such report shall include— 

13 (1) a description and evaluation of the activities 

14 carried out under this Act; 

15 (2) a description and analysis of best practices, 

16 model programs, guidelines, and other effective 

17 strategies for providing access to culturally and lin18 guistically appropriate health care services; 

19 (3) recommendations on the development and 

20 implementation of policies and practices by providers 

21 of health care and health-care-related services for 

22 limited-English-proficient individuals; 

23 (4) recommend guidelines or standards for 

24 health literacy and plain language, informed consent, 

25 discharge instructions, and written communications, 

26 and for improvement of health care access; 


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1 (5) a description of the effect of providing lan2 guage services on quality of health care and access 

3 to care; and 

4 (6) a description of the costs associated with or 

5 savings related to the provision of language services. 

6 (b) AUTHORIZATION OF APPROPRIATIONS.—There 

7 are authorized to be appropriated to carry out this section 

8 such sums as may be necessary for each of fiscal years 

9 2019 through 2023. 

10 SEC. 209. ENGLISH FOR SPEAKERS OF OTHER LANGUAGES. 

11 (a) GRANTS AUTHORIZED.—The Secretary of Edu12 cation is authorized to provide grants to eligible entities 

13 for the provision of English as a second language (in this 

14 section referred to ‘‘ESL’’) instruction and shall deter15 mine, after consultation with appropriate stakeholders, the 

16 mechanism for administering and distributing such 

17 grants. 

18 (b) ELIGIBLE ENTITY DEFINED.—For purposes of 

19 this section, the term ‘‘eligible entity’’ means a State or 

20 community-based organization that employs, and serves, 

21 minority populations. 

22 (c) APPLICATION.—An eligible entity may apply for 

23 a grant under this section by submitting such information 

24 as the Secretary may require and in such form and man25 ner as the Secretary may require. 


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1 (d) USE OF GRANT.—As a condition of receiving a 

2 grant under this section, an eligible entity shall— 

3 (1) develop and implement a plan for assuring 

4 the availability of ESL instruction that effectively 

5 integrates information about the nature of the 

6 United States health care system, how to access 

7 care, and any special language skills that may be re8 quired for them to access and regularly negotiate the 

9 system effectively; 

10 (2) develop a plan, including, where appro11 priate, public-private partnerships, for making ESL 

12 instruction progressively available to all individuals 

13 seeking instruction; and 

14 (3) maintain current ESL instruction efforts by 

15 using the additional funds to supplement rather 

16 than supplant any funds expended for ESL instruc17 tion in the State as of January 1, 2019. 

18 (e) ADDITIONAL DUTIES OF THE SECRETARY.—The 

19 Secretary of Education shall— 

20 (1) collect and publicize annual data on how 

21 much Federal, State, and local governments spend 

22 on ESL instruction; 

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1 guage learners for appropriate ESL instruction, in2 cluding— 

3 (A) the preferred written and spoken lan4 guage of such English language learners; 

5 (B) the extent of waiting lists including 

6 how many programs maintain waiting lists and, 

7 for programs that do not have waiting lists, the 

8 reasons why not; 

9 (C) the availability of programs to geo10 graphically isolated communities; 

11 (D) the impact of course enrollment poli12 cies, including open enrollment, on the avail13 ability of ESL instruction; 

14 (E) the number individuals in the State 

15 and each participating locality; 

16 (F) the effectiveness of the instruction in 

17 meeting the needs of individuals receiving in18 struction and those needing instruction; 

19 (G) as assessment of the need for pro20 grams that integrate job training and ESL in21 struction, to assist individuals to obtain better 

22 jobs; and 

23 (H) the availability of ESL slots by State 

24 and locality; 


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1 (3) determine the cost and most appropriate 

2 methods of making ESL instruction available to all 

3 English language learners seeking instruction; and 

4 (4) not later than 1 year after the date of en5 actment of this Act, issue a report to Congress that 

6 assesses the information collected in paragraphs (1), 

7 (2), and (3) and makes recommendations on steps 

8 that should be taken to progressively realize the goal 

9 of making ESL instruction available to all English 

10 language learners seeking instruction. 

11 (f) AUTHORIZATION OF APPROPRIATIONS.—There 

12 are authorized to be appropriated to the Secretary of Edu13 cation $250,000,000 for each of fiscal years 2019 through 

14 2022 to carry out this section. 

15 SEC. 210. IMPLEMENTATION. 

16 (a) GENERAL PROVISIONS.— 

17 (1) A State shall not be immune under the 

18 Eleventh Amendment of the Constitution of the 

19 United States from suit in Federal court for failing 

20 to provide the language access funded pursuant to 

21 this title. 

22 (2) In a suit against a State for a violation of 

23 this title, remedies (including remedies at both at 

24 law and in equity) are available for such a violation 

25 to the same extent as such remedies are available for 


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1 such a violation in the suit against any public or pri2 vate entity other than a State. 

3 (b) RULE OF CONSTRUCTION.—Nothing in this title 

4 shall be construed to limit otherwise existing obligations 

5 of recipients of Federal financial assistance under title VI 

6 of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et 

7 seq.) or any other statute. 

8 SEC. 211. LANGUAGE ACCESS SERVICES. 

9 (a) ESSENTIAL BENEFITS.—Section 1302(b)(1) of 

10 the Patient Protection and Affordable Care Act (42 

11 U.S.C. 18022(b)(1)) is amended by adding at the end the 

12 following: 

13 ‘‘(K) Language access services, including 

14 oral interpretation and written translations.’’. 

15 (b) EMPLOYER-SPONSORED MINIMUM ESSENTIAL

16 COVERAGE.— 

17 (1) IN GENERAL.—Section 36B(c)(2)(C) of the 

18 Internal Revenue Code of 1986 is amended by redes19 ignating clauses (iii) and (iv) as clauses (iv) and (v), 

20 respectively, and by inserting after clause (ii) the fol21 lowing new clause: 

22 ‘‘(iii) COVERAGE MUST INCLUDE LAN23 GUAGE ACCESS AND SERVICES.—Except as 

24 provided in clause (iv), an employee shall 

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1 sential coverage if such coverage consists 

2 of an eligible employer-sponsored plan (as 

3 defined in section 5000A(f)(2)) and the 

4 plan does not provide coverage for lan5 guage access services, including oral inter6 pretation and written translations.’’. 

7 (2) CONFORMING AMENDMENTS.— 

8 (A) Section 36B(c)(2)(C) of such Code is 

9 amended by striking ‘‘clause (iii)’’ each place it 

10 appears in clauses (i) and (ii) and inserting 

11 ‘‘clause (iv)’’. 

12 (B) Section 36B(c)(2)(C)(iv) of such Code, 

13 as redesignated by this subsection, is amended 

14 by striking ‘‘(i) and (ii)’’ and inserting ‘‘(i), (ii), 

15 and (iii)’’. 

16 (c) QUALITY REPORTING.—Section 2717(a)(1) of the 

17 Public Health Service Act (42 U.S.C. 300gg–17(a)(1)) is 

18 amended— 

19 (1) by striking ‘‘and’’ at the end of subpara20 graph (C); 

21 (2) by striking the period at the end of sub22 paragraph (D) and inserting ‘‘; and’’; and 

23 (3) by adding at the end the following new sub24 paragraph: 


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1 ‘‘(E) reduce health disparities through the 

2 provision of language access services, including 

3 oral interpretation and written translations.’’. 

4 (d) REGULATIONS REGARDING INTERNAL CLAIMS

5 AND APPEALS AND EXTERNAL REVIEW PROCESSES FOR

6 HEALTH PLANS AND HEALTH INSURANCE ISSUERS.— 

7 The Secretary of the Treasury, the Secretary of Labor, 

8 and the Secretary of Health and Human Services shall 

9 amend the regulations in section 54.9815–2719T(e) of 

10 title 26, Code of Federal Regulations, section 2590.715– 

11 2719(e) of title 29, Code of Federal Regulations, and sec12 tion 147.136(e) of title 45, Code of Federal Regulations, 

13 respectively, to require group health plans and health in14 surance issuers offering group or individual health insur15 ance coverage to which such sections apply— 

16 (1) to provide oral interpretation services with17 out any threshold requirements; 

18 (2) to provide in the English versions of all no19 tices a statement prominently displayed in not less 

20 than 15 non-English languages clearly indicating 

21 how to access the language services provided by the 

22 plan or issuer; and 

23 (3) with respect to written translations of no24 tices, to apply a threshold that 5 percent of the pop25 ulation or at least 500 individuals per service area 


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1 are literate only in the same non-English language 

2 in lieu of 10 percent or more residing in a county. 

3 (e) DATA COLLECTION AND REPORTING.—The Sec4 retary of Health and Human Services shall— 

5 (1) amend the single streamlined application 

6 form developed pursuant to section 1413 of the Pa7 tient Protection and Affordable Care Act (42 U.S.C. 

8 18083) to collect the preferred spoken and written 

9 language for each household member applying for 

10 coverage under a qualified health plan through an 

11 Exchange under title I of the Patient Protection and 

12 Affordable Care Act; 

13 (2) require navigators, certified application 

14 counselors, and other enrollment assisters to collect 

15 and report requests for language assistance; and 

16 (3) require the Federal and State call centers 

17 established pursuant to section 1311(d)(4)(b) of the 

18 Patient Protection and Affordable Care Act (42 

19 U.S.C. 18031(d)(4)(b)) to submit an annual report 

20 documenting the number of language assistance re21 quests, the types of languages requested, the range 

22 and average wait time for a consumer to speak with 

23 an interpreter, and any steps the call center and lan24 guage line have taken to actively address some of 

25 the consumer complaints. 


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1 (f) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to plan years beginning after the 

3 date of the enactment of this Act. 

4 TITLE III—HEALTH WORKFORCE 

5 DIVERSITY 

6 SEC. 301. AMENDMENT TO THE PUBLIC HEALTH SERVICE 

7 ACT. 

8 Title XXXIV of the Public Health Service Act, as 

9 added by section 202, is amended by adding at the end 

10 the following: 

11 ‘‘Subtitle A—Diversifying the 

12 Health Care Workplace 

13 ‘‘SEC. 3411. NATIONAL WORKING GROUP ON WORKFORCE 

14 DIVERSITY. 

15 ‘‘(a) IN GENERAL.—The Secretary, acting through 

16 the Bureau of Health Workforce within the Health Re17 sources and Services Administration, shall award a grant 

18 to an entity determined appropriate by the Secretary for 

19 the establishment of a national working group on work20 force diversity. 

21 ‘‘(b) REPRESENTATION.—In establishing the national 

22 working group under subsection (a): 

23 ‘‘(1) The grantee shall ensure that the group 

24 has representatives of the following: 


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1 ‘‘(A) The Health Resources and Services 

2 Administration. 

3 ‘‘(B) The Department of Health and 

4 Human Services Data Council. 

5 ‘‘(C) The Office of Minority Health of the 

6 Department of Health and Human Services. 

7 ‘‘(D) The Substance Abuse and Mental 

8 Health Services Administration. 

9 ‘‘(E) The Bureau of Labor Statistics of 

10 the Department of Labor. 

11 ‘‘(F) The Public Health Practice Program 

12 Office—Office of Workforce Policy and Plan13 ning. 

14 ‘‘(G) The National Institute on Minority 

15 Health and Health Disparities. 

16 ‘‘(H) The Agency for Healthcare Research 

17 and Quality. 

18 ‘‘(I) The Institute of Medicine Study Com19 mittee for the 2004 workforce diversity report. 

20 ‘‘(J) The Indian Health Service. 

21 ‘‘(K) The Department of Education. 

22 ‘‘(L) Minority-serving academic institu23 tions. 

24 ‘‘(M) Consumer organizations. 


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1 ‘‘(N) Health professional associations, in2 cluding those that represent underrepresented 

3 minority populations. 

4 ‘‘(O) Researchers in the area of health 

5 workforce. 

6 ‘‘(P) Health workforce accreditation enti7 ties. 

8 ‘‘(Q) Private (including nonprofit) founda9 tions that have sponsored workforce diversity 

10 initiatives. 

11 ‘‘(R) Local and State health departments. 

12 ‘‘(S) Representatives of community mem13 bers to be included on admissions committees 

14 for health profession schools pursuant to sub15 section (c)(8). 

16 ‘‘(T) National community-based organiza17 tions that serve as a national intermediary to 

18 their urban affiliate members and have dem19 onstrated capacity to train health care profes20 sionals. 

21 ‘‘(U) Other entities determined appropriate 

22 by the Secretary. 

23 ‘‘(V) The Veterans Health Administration. 

24 ‘‘(2) The grantee shall ensure that, in addition 

25 to the representatives under paragraph (1), the 


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1 group has not less than 5 health professions stu2 dents representing various health profession fields 

3 and levels of training. 

4 ‘‘(c) ACTIVITIES.—The working group established 

5 under subsection (a) shall convene at least twice each year 

6 to complete the following activities: 

7 ‘‘(1) Review current public and private health 

8 workforce diversity initiatives. 

9 ‘‘(2) Identify successful health workforce diver10 sity programs and practices. 

11 ‘‘(3) Examine challenges relating to the devel12 opment and implementation of health workforce di13 versity initiatives. 

14 ‘‘(4) Draft a national strategic work plan for 

15 health workforce diversity, including recommenda16 tions for public and private sector initiatives. 

17 ‘‘(5) Develop a framework and methods for the 

18 evaluation of current and future health workforce di19 versity initiatives. 

20 ‘‘(6) Develop recommended standards for work21 force diversity that could be applicable to all health 

22 professions programs and programs funded under 

23 this Act. 

24 ‘‘(7) Develop guidelines to train health profes25 sionals to care for a diverse population. 


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1 ‘‘(8) Develop a workforce data collection or 

2 tracking system to identify where racial and ethnic 

3 minority health professionals practice. 

4 ‘‘(9) Develop a strategy for the inclusion of 

5 community members on admissions committees for 

6 health profession schools. 

7 ‘‘(10) Helping with monitoring and implementa8 tion of standards for diversity, equity, and inclusion. 

9 ‘‘(11) Other activities determined appropriate 

10 by the Secretary. 

11 ‘‘(d) ANNUAL REPORT.—Not later than 1 year after 

12 the establishment of the working group under subsection 

13 (a), and annually thereafter, the working group shall pre14 pare and make available to the general public for com15 ment, an annual report on the activities of the working 

16 group. Such report shall include the recommendations of 

17 the working group for improving health workforce diver18 sity. 

19 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

20 is authorized to be appropriated to carry out this section 

21 such sums as may be necessary for each of fiscal years 

22 2019 through 2024. 


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1 ‘‘SEC. 3412. TECHNICAL CLEARINGHOUSE FOR HEALTH 

2 WORKFORCE DIVERSITY. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Deputy Assistant Secretary for Minority Health, and 

5 in collaboration with the Bureau of Health Workforce 

6 within the Health Resources and Services Administration, 

7 the National Institute on Minority Health and Health Dis8 parities, shall establish a technical clearinghouse on health 

9 workforce diversity within the Office of Minority Health 

10 and coordinate current and future clearinghouses. 

11 ‘‘(b) INFORMATION AND SERVICES.—The clearing12 house established under subsection (a) shall offer the fol13 lowing information and services: 

14 ‘‘(1) Information on the importance of health 

15 workforce diversity. 

16 ‘‘(2) Statistical information relating to under17 represented minority representation in health and al18 lied health professions and occupations. 

19 ‘‘(3) Model health workforce diversity practices 

20 and programs, including integrated models of care. 

21 ‘‘(4) Admissions policies that promote health 

22 workforce diversity and are in compliance with Fed23 eral and State laws. 

24 ‘‘(5) Retainment policies that promote comple25 tion of health profession degrees for underserved 

26 populations. 


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1 ‘‘(6) Lists of scholarship, loan repayment, and 

2 loan cancellation grants as well as fellowship infor3 mation for underserved populations for health pro4 fessions schools. 

5 ‘‘(7) Foundation and other large organizational 

6 initiatives relating to health workforce diversity. 

7 ‘‘(c) CONSULTATION.—In carrying out this section, 

8 the Secretary shall consult with non-Federal entities which 

9 may include minority health professional associations and 

10 minority sections of major health professional associations 

11 to ensure the adequacy and accuracy of information. 

12 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

13 is authorized to be appropriated to carry out this section 

14 such sums as may be necessary for each of fiscal years 

15 2019 through 2024. 

16 ‘‘SEC. 3413. SUPPORT FOR INSTITUTIONS COMMITTED TO 

17 WORKFORCE DIVERSITY, EQUITY, AND IN18 CLUSION. 

19 ‘‘(a) IN GENERAL.—The Secretary, acting through 

20 the Administrator of the Health Resources and Services 

21 Administration and the Centers for Disease Control and 

22 Prevention, shall award grants to eligible entities that 

23 demonstrate a commitment to health workforce diversity. 

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

25 under subsection (a), an entity shall— 


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1 ‘‘(1) be an educational institution or entity that 

2 historically produces or trains meaningful numbers 

3 of underrepresented minority health professionals, 

4 including— 

5 ‘‘(A) historically Black colleges and univer6 sities; 

7 ‘‘(B) Hispanic-serving health professions 

8 schools; 

9 ‘‘(C) Hispanic-serving institutions; 

10 ‘‘(D) Tribal colleges and universities; 

11 ‘‘(E) Asian-American, Native American, 

12 and Pacific Islander-serving institutions; 

13 ‘‘(F) institutions that have programs to re14 cruit and retain underrepresented minority 

15 health professionals, in which a significant 

16 number of the enrolled participants are under17 represented minorities; 

18 ‘‘(G) health professional associations, 

19 which may include underrepresented minority 

20 health professional associations; and 

21 ‘‘(H) institutions, including national and 

22 regional community-based organizations with 

23 demonstrated commitment to a diversified 

24 workforce— 


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1 ‘‘(i) located in communities with pre2 dominantly underrepresented minority pop3 ulations; 

4 ‘‘(ii) with whom partnerships have 

5 been formed for the purpose of increasing 

6 workforce diversity; and 

7 ‘‘(iii) in which at least 20 percent of 

8 the enrolled participants are underrep9 resented minorities; and 

10 ‘‘(2) submit to the Secretary an application at 

11 such time, in such manner, and containing such in12 formation as the Secretary may require. 

13 ‘‘(c) USE OF FUNDS.—Amounts received under a 

14 grant under subsection (a) shall be used to expand existing 

15 workforce diversity programs, implement new workforce 

16 diversity programs, or evaluate existing or new workforce 

17 diversity programs, including with respect to mental 

18 health care professions. Such programs shall enhance di19 versity by considering minority status as part of an indi20 vidualized consideration of qualifications. Possible activi21 ties may include— 

22 ‘‘(1) educational outreach programs relating to 

23 opportunities in the health professions; 

24 ‘‘(2) scholarship, fellowship, grant, loan repay25 ment, and loan cancellation programs; 


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1 ‘‘(3) postbaccalaureate programs; 

2 ‘‘(4) academic enrichment programs, particu3 larly targeting those who would not be competitive 

4 for health professions schools; 

5 ‘‘(5) kindergarten through 12th grade and 

6 other health pipeline programs; 

7 ‘‘(6) mentoring programs; 

8 ‘‘(7) internship or rotation programs involving 

9 hospitals, health systems, health plans, and other 

10 health entities; 

11 ‘‘(8) community partnership development for 

12 purposes relating to workforce diversity; or 

13 ‘‘(9) leadership training. 

14 ‘‘(d) REPORTS.—Not later than 1 year after receiving 

15 a grant under this section, and annually for the term of 

16 the grant, a grantee shall submit to the Secretary a report 

17 that summarizes and evaluates all activities conducted 

18 under the grant. 

19 ‘‘(e) DEFINITION.—In this section, the term ‘Asian20 American, Native American, and Pacific Islander-serving 

21 institutions’ has the same meaning as the term ‘Asian 

22 American and Native American Pacific Islander-serving 

23 institution’ as defined in section 371(c) of the Higher 

24 Education Act of 1965 (20 U.S.C. 1067q(c)). 


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1 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

2 is authorized to be appropriated to carry out this section, 

3 such sums as may be necessary for each of fiscal years 

4 2019 through 2024. 

5 ‘‘SEC. 3414. CAREER DEVELOPMENT FOR SCIENTISTS AND 

6 RESEARCHERS. 

7 ‘‘(a) IN GENERAL.—The Secretary, acting through 

8 the Director of the National Institutes of Health, the Di9 rector of the Centers for Disease Control and Prevention, 

10 the Commissioner of Food and Drugs, the Director of the 

11 Agency for Healthcare Research and Quality, and the Ad12 ministrator of the Health Resources and Services Admin13 istration, shall award grants that expand existing opportu14 nities for scientists and researchers and promote the inclu15 sion of underrepresented minorities in the health profes16 sions. 

17 ‘‘(b) RESEARCH FUNDING.—The head of each entity 

18 within the Department of Health and Human Services 

19 shall establish or expand existing programs to provide re20 search funding to scientists and researchers in training. 

21 Under such programs, the head of each such entity shall 

22 give priority in allocating research funding to support 

23 health research in traditionally underserved communities, 

24 including underrepresented minority communities, and re25 search classified as community or participatory. 


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1 ‘‘(c) DATA COLLECTION.—The head of each entity 

2 within the Department of Health and Human Services 

3 shall collect data on the number (expressed as an absolute 

4 number and a percentage) of underrepresented minority 

5 and nonminority applicants who receive and are denied 

6 agency funding at every stage of review. Such data shall 

7 be reported annually to the Secretary and the appropriate 

8 committees of Congress. 

9 ‘‘(d) STUDENT LOAN REIMBURSEMENT.—The Sec10 retary shall establish a student loan reimbursement pro11 gram to provide student loan reimbursement assistance to 

12 researchers who focus on racial and ethnic disparities in 

13 health. The Secretary shall promulgate regulations to de14 fine the scope and procedures for the program under this 

15 subsection. 

16 ‘‘(e) STUDENT LOAN CANCELLATION.—The Sec17 retary shall establish a student loan cancellation program 

18 to provide student loan cancellation assistance to research19 ers who focus on racial and ethnic disparities in health. 

20 Students participating in the program shall make a min21 imum 5-year commitment to work at an accredited health 

22 profession school. The Secretary shall promulgate addi23 tional regulations to define the scope and procedures for 

24 the program under this subsection. 


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1 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

2 is authorized to be appropriated to carry out this section, 

3 such sums as may be necessary for each of fiscal years 

4 2019 through 2024. 

5 ‘‘SEC. 3415. CAREER SUPPORT FOR NONRESEARCH HEALTH 

6 PROFESSIONALS. 

7 ‘‘(a) IN GENERAL.—The Secretary, acting through 

8 the Director of the Centers for Disease Control and Pre9 vention, the Administrator of the Substance Abuse and 

10 Mental Health Services Administration, the Administrator 

11 of the Health Resources and Services Administration, and 

12 the Administrator of the Centers for Medicare & Medicaid 

13 Services, shall establish a program to award grants to eli14 gible individuals for career support in nonresearch-related 

15 health and wellness professions. 

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

17 under subsection (a), an individual shall— 

18 ‘‘(1) be a student in a health professions school, 

19 a graduate of such a school who is working in a 

20 health profession, an individual working in a health 

21 or wellness profession (including mental and behav22 ioral health), or a faculty member of such a school; 

23 and 


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1 ‘‘(2) submit to the Secretary an application at 

2 such time, in such manner, and containing such in3 formation as the Secretary may require. 

4 ‘‘(c) USE OF FUNDS.—An individual shall use 

5 amounts received under a grant under this section to— 

6 ‘‘(1) support the individual’s health activities or 

7 projects that involve underserved communities, in8 cluding racial and ethnic minority communities; 

9 ‘‘(2) support health-related career advancement 

10 activities; 

11 ‘‘(3) to pay, or as reimbursement for payments 

12 of, student loans or training or credentialing costs 

13 for individuals who are health professionals and are 

14 focused on health issues affecting underserved com15 munities, including racial and ethnic minority com16 munities; and 

17 ‘‘(4) to establish and promote leadership train18 ing programs to decrease health disparities and to 

19 increase cultural competence with the goal of in20 creasing diversity in leadership positions. 

21 ‘‘(d) DEFINITION.—In this section, the term ‘career 

22 in nonresearch-related health and wellness professions’ 

23 means employment or intended employment in the field 

24 of public health, health policy, health management, health 

25 administration, medicine, nursing, pharmacy, psychology, 


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1 social work, psychiatry, other mental and behavioral 

2 health, allied health, community health, social work, or 

3 other fields determined appropriate by the Secretary, 

4 other than in a position that involves research. 

5 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

6 is authorized to be appropriated to carry out this section 

7 such sums as may be necessary for each of fiscal years 

8 2019 through 2024. 

9 ‘‘SEC. 3416. RESEARCH ON THE EFFECT OF WORKFORCE DI10 VERSITY ON QUALITY. 

11 ‘‘(a) IN GENERAL.—The Director of the Agency for 

12 Healthcare Research and Quality, in collaboration with 

13 the Deputy Assistant Secretary for Minority Health and 

14 the Director of the National Institute on Minority Health 

15 and Health Disparities, shall award grants to eligible enti16 ties to expand research on the link between health work17 force diversity and quality health care. 

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

19 under subsection (a), an entity shall— 

20 ‘‘(1) be a clinical, public health, or health serv21 ices research entity or other entity determined ap22 propriate by the Director; and 

23 ‘‘(2) submit to the Secretary an application at 

24 such time, in such manner, and containing such in25 formation as the Secretary may require. 


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1 ‘‘(c) USE OF FUNDS.—Amounts received under a 

2 grant awarded under subsection (a) shall be used to sup3 port research that investigates the effect of health work4 force diversity on— 

5 ‘‘(1) language access; 

6 ‘‘(2) cultural competence; 

7 ‘‘(3) patient satisfaction; 

8 ‘‘(4) timeliness of care; 

9 ‘‘(5) safety of care; 

10 ‘‘(6) effectiveness of care; 

11 ‘‘(7) efficiency of care; 

12 ‘‘(8) patient outcomes; 

13 ‘‘(9) community engagement; 

14 ‘‘(10) resource allocation; 

15 ‘‘(11) organizational structure; 

16 ‘‘(12) compliance of care; or 

17 ‘‘(13) other topics determined appropriate by 

18 the Director. 

19 ‘‘(d) PRIORITY.—In awarding grants under sub20 section (a), the Director shall give individualized consider21 ation to all relevant aspects of the applicant’s background. 

22 Consideration of prior research experience involving the 

23 health of underserved communities shall be such a factor. 

24 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

25 is authorized to be appropriated to carry out this section 


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1 such sums as may be necessary for each of fiscal years 

2 2019 through 2024. 

3 ‘‘SEC. 3417. HEALTH DISPARITIES EDUCATION PROGRAM. 

4 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

5 through the National Institute on Minority Health and 

6 Health Disparities and in collaboration with the Office of 

7 Minority Health, the Office for Civil Rights, the Centers 

8 for Disease Control and Prevention, the Centers for Medi9 care & Medicaid Services, the Health Resources and Serv10 ices Administration, and other appropriate public and pri11 vate entities, shall establish and coordinate a health and 

12 health care disparities education program to support, de13 velop, and implement educational initiatives and outreach 

14 strategies that inform health care professionals and the 

15 public about the existence of and methods to reduce racial 

16 and ethnic disparities in health and health care. 

17 ‘‘(b) ACTIVITIES.—The Secretary, through the edu18 cation program established under subsection (a), shall, 

19 through the use of public awareness and outreach cam20 paigns targeting the general public and the medical com21 munity at large— 

22 ‘‘(1) disseminate scientific evidence for the ex23 istence and extent of racial and ethnic disparities in 

24 health care, including disparities that are not other25 wise attributable to known factors such as access to 


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1 care, patient preferences, or appropriateness of 

2 intervention, as described in the 2002 Institute of 

3 Medicine Report entitled ‘Unequal Treatment: Con4 fronting Racial and Ethnic Disparities in Health 

5 Care’, as well as the impact of disparities related to 

6 age, disability status, socioeconomic status, sex, gen7 der identity, and sexual orientation on racial and 

8 ethnic minorities; 

9 ‘‘(2) disseminate new research findings to 

10 health care providers and patients to assist them in 

11 understanding, reducing, and eliminating health and 

12 health care disparities; 

13 ‘‘(3) disseminate information about the impact 

14 of linguistic and cultural barriers on health care 

15 quality and the obligation of health providers who 

16 receive Federal financial assistance to ensure that 

17 people with limited-English proficiency have access 

18 to language access services; 

19 ‘‘(4) disseminate information about the impor20 tance and legality of racial, ethnic, disability status, 

21 socioeconomic status, sex, gender identity, and sex22 ual orientation, and primary language data collec23 tion, analysis, and reporting; 


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1 ‘‘(5) design and implement specific educational 

2 initiatives to health care providers relating to health 

3 and health care disparities; 

4 ‘‘(6) assess the impact of the programs estab5 lished under this section in raising awareness of 

6 health and health care disparities and providing in7 formation on available resources; and 

8 ‘‘(7) design and implement specific educational 

9 initiatives to educate the health care workforce relat10 ing to unconscious bias. 

11 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There 

12 is authorized to be appropriated to carry out this section 

13 such sums as may be necessary for each of fiscal years 

14 2019 through 2024.’’. 

15 SEC. 302. HISPANIC-SERVING HEALTH PROFESSIONS 

16 SCHOOLS. 

17 Part B of title VII of the Public Health Service Act 

18 (42 U.S.C. 293 et seq.) is amended by adding at the end 

19 the following: 

20 ‘‘SEC. 742. HISPANIC-SERVING INSTITUTIONS, HISTORI21 CALLY BLACK COLLEGES & UNIVERSITIES, 

22 AND TRIBAL COLLEGES. 

23 ‘‘(a) IN GENERAL.—The Secretary, acting through 

24 the Administrator of the Health and Human Resources 

25 and Services Administration, shall establish grants from 


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1 the Department of Education to Hispanic-serving Institu2 tions, Historically Black Colleges & Universities, and Trib3 al Colleges, including Regional community based organiza4 tions and national minority medical associations, for schol5 arships and counseling services to prepare underrep6 resented minority individuals to enroll in and graduate 

7 from health professional schools and to increase services 

8 for qualified students, including— 

9 ‘‘(1) mentoring with underrepresented health 

10 professionals; and 

11 ‘‘(2) providing financial assistance information 

12 for continued education and applications to health 

13 professional schools. 

14 ‘‘(b) ELIGIBILITY.—In subsection (a), the term ‘His15 panic-serving Institutions’ means an entity that— 

16 ‘‘(1) is a school or program under section 

17 799B; 

18 ‘‘(2) has an enrollment of full-time equivalent 

19 students that is made up of at least 9 percent His20 panic students; 

21 ‘‘(3) has been effective in carrying out pro22 grams to recruit Hispanic individuals to enroll in 

23 and graduate from the school; 

24 ‘‘(4) has been effective in recruiting and retain25 ing Hispanic faculty members; 


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1 ‘‘(5) has a significant number of graduates who 

2 are providing health services to medically under3 served populations or to individuals in health profes4 sional shortage areas; and 

5 ‘‘(6) is a Regional Hispanic Center of Excel6 lence. 

7 ‘‘(c) CERTAIN LOAN REPAYMENT PROGRAMS.—In 

8 carrying out the National Health Service Corps loan re9 payment program and loan repayment programs of the 

10 Centers for Disease Control and Prevention, the Secretary 

11 shall ensure that loan repayments of not less than $50,000 

12 per year are awarded for repayment of loans incurred for 

13 enrollment or participation in schools and programs de14 scribed in this section.’’. 

15 SEC. 303. LOAN REPAYMENT PROGRAM OF CENTERS FOR 

16 DISEASE CONTROL AND PREVENTION. 

17 Section 317F(c) of the Public Health Service Act (42 

18 U.S.C. 247b–7(c)) is amended— 

19 (1) by striking ‘‘and’’ after ‘‘1994,’’; and 

20 (2) by inserting before the period at the end the 

21 following: ‘‘, $750,000 for fiscal year 2019, and such 

22 sums as may be necessary for each of the fiscal 

23 years 2020 through 2024’’. 


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1 SEC. 304. COOPERATIVE AGREEMENTS FOR ONLINE DE2 GREE PROGRAMS AT SCHOOLS OF PUBLIC 

3 HEALTH AND SCHOOLS OF ALLIED HEALTH. 

4 Part B of title VII of the Public Health Service Act 

5 (42 U.S.C. 293 et seq.), as amended by section 302, is 

6 further amended by adding at the end the following: 

7 ‘‘SEC. 743. COOPERATIVE AGREEMENTS FOR ONLINE DE8 GREE PROGRAMS. 

9 ‘‘(a) COOPERATIVE AGREEMENTS.—The Secretary, 

10 acting through the Administrator of the Health Resources 

11 and Services Administration, in consultation with the Di12 rector of the Centers for Disease Control and Prevention, 

13 the Director of the Agency for Healthcare Research and 

14 Quality, and the Deputy Assistant Secretary for Minority 

15 Health, shall award cooperative agreements to schools of 

16 public health and schools of allied health to design and 

17 implement online degree programs. 

18 ‘‘(b) PRIORITY.—In awarding cooperative agreements 

19 under this section, the Secretary shall give priority to any 

20 school of public health or school of allied health that has 

21 an established track record of serving medically under22 served communities. 

23 ‘‘(c) REQUIREMENTS.—Recipients of cooperative 

24 agreements under this section shall design and implement 

25 an online degree program that meets the following restric26 tions: 


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1 ‘‘(1) Enrollment of individuals who have ob2 tained a secondary school diploma or its recognized 

3 equivalent. 

4 ‘‘(2) Maintaining a significant enrollment of 

5 underrepresented minority or disadvantaged stu6 dents. 

7 ‘‘(3) Achieving a high completion rate of en8 rolled underrepresented minority or disadvantaged 

9 students. 

10 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

11 are authorized to be appropriated to carry out this section 

12 such sums as may be necessary for each of fiscal years 

13 2019 through 2024.’’. 

14 SEC. 305. SENSE OF CONGRESS ON THE MISSION OF THE 

15 NATIONAL HEALTH CARE WORKFORCE COM16 MISSION. 

17 It is the sense of Congress that the National Health 

18 Care Workforce Commission established by section 5101 

19 of the Patient Protection and Affordable Care Act (42 

20 U.S.C. 294q) should, in carrying out its assigned duties 

21 under that section, give attention to the needs of racial 

22 and ethnic minorities, individuals with lower socio23 economic status, individuals with mental, developmental, 

24 and physical disabilities, lesbian, gay, bisexual, 

25 transgender, queer, and questioning populations, and indiVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00157 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 viduals who are members of multiple minority or special 

2 population groups. 

3 SEC. 306. SCHOLARSHIP AND FELLOWSHIP PROGRAMS. 

4 Subtitle A of title XXXIV of the Public Health Serv5 ice Act, as added by section 301, is further amended by 

6 inserting after section 3417 the following: 

7 ‘‘SEC. 3418. DAVID SATCHER PUBLIC HEALTH AND HEALTH 

8 SERVICES CORPS. 

9 ‘‘(a) IN GENERAL.—The Administrator of the Health 

10 Resources and Services Administration and the Director 

11 of the Centers for Disease Control and Prevention, in col12 laboration with the Deputy Assistant Secretary for Minor13 ity Health, shall award grants to eligible entities to in14 crease awareness among postprimary and postsecondary 

15 students of career opportunities in the health professions. 

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

17 under subsection (a), an entity shall— 

18 ‘‘(1) be a clinical, public health, or health serv19 ices organization, community-based or nonprofit en20 tity, or other entity determined appropriate by the 

21 Director of the Centers for Disease Control and Pre22 vention; 

23 ‘‘(2) serve a health professional shortage area, 

24 as determined by the Secretary; 


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1 ‘‘(3) work with students, including those from 

2 racial and ethnic minority backgrounds, that have 

3 expressed an interest in the health professions; and 

4 ‘‘(4) submit to the Secretary an application at 

5 such time, in such manner, and containing such in6 formation as the Secretary may require. 

7 ‘‘(c) USE OF FUNDS.—Grant awards under sub8 section (a) shall be used to support internships that will 

9 increase awareness among students of non-research-based, 

10 career opportunities in the following health professions: 

11 ‘‘(1) Medicine. 

12 ‘‘(2) Nursing. 

13 ‘‘(3) Public Health. 

14 ‘‘(4) Pharmacy. 

15 ‘‘(5) Health administration and management. 

16 ‘‘(6) Health policy. 

17 ‘‘(7) Psychology. 

18 ‘‘(8) Dentistry. 

19 ‘‘(9) International health. 

20 ‘‘(10) Social work. 

21 ‘‘(11) Allied health. 

22 ‘‘(12) Psychiatry. 

23 ‘‘(13) Hospice care. 

24 ‘‘(14) Community health, patient navigation, 

25 and peer support. 


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1 ‘‘(15) Other professions deemed appropriate by 

2 the Director of the Centers for Disease Control and 

3 Prevention. 

4 ‘‘(d) PRIORITY.—In awarding grants under sub5 section (a), the Director of the Centers for Disease Con6 trol and Prevention shall give priority to those entities 

7 that— 

8 ‘‘(1) serve a high proportion of individuals from 

9 disadvantaged backgrounds; 

10 ‘‘(2) have experience in health disparity elimi11 nation programs; 

12 ‘‘(3) facilitate the entry of disadvantaged indi13 viduals into institutions of higher education; and 

14 ‘‘(4) provide counseling or other services de15 signed to assist disadvantaged individuals in success16 fully completing their education at the postsecondary 

17 level. 

18 ‘‘(e) STIPENDS.—The Secretary may approve sti19 pends under this section for individuals for any period of 

20 education in student-enhancement programs (other than 

21 regular courses) at health professions schools, programs, 

22 or entities, except that such a stipend may not be provided 

23 to an individual for more than 6 months, and such a sti24 pend may not exceed $20 per day (notwithstanding any 

25 other provision of law regarding the amount of stipends). 


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1 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

2 is authorized to be appropriated to carry out this section 

3 such sums as may be necessary for each of fiscal years 

4 2019 through 2024. 

5 ‘‘SEC. 3419. LOUIS STOKES PUBLIC HEALTH SCHOLARS 

6 PROGRAM. 

7 ‘‘(a) IN GENERAL.—The Director of the Centers for 

8 Disease Control and Prevention, in collaboration with the 

9 Deputy Assistant Secretary for Minority Health, shall 

10 award scholarships to postsecondary students who seek a 

11 career in public health. 

12 ‘‘(b) ELIGIBILITY.—To be eligible to receive a schol13 arship under subsection (a), an individual shall— 

14 ‘‘(1) have interest, knowledge, or skill in public 

15 health research or public health practice, or other 

16 health professions as determined appropriate by the 

17 Director of the Centers for Disease Control and Pre18 vention; 

19 ‘‘(2) reside in a health professional shortage 

20 area as determined by the Secretary; 

21 ‘‘(3) demonstrate promise for becoming a leader 

22 in public health; 

23 ‘‘(4) secure admission to a 4-year institution of 

24 higher education; 

25 ‘‘(5) comply with subsection (e); and 


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1 ‘‘(6) submit to the Secretary an application at 

2 such time, in such manner, and containing such in3 formation as the Secretary may require. 

4 ‘‘(c) USE OF FUNDS.—Amounts received under an 

5 award under subsection (a) shall be used to support oppor6 tunities for students to become public health professionals. 

7 ‘‘(d) PRIORITY.—In awarding grants under sub8 section (a), the Director shall give priority to those stu9 dents that— 

10 ‘‘(1) are from disadvantaged backgrounds; 

11 ‘‘(2) have secured admissions to a minority12 serving institution; and 

13 ‘‘(3) have identified a health professional as a 

14 mentor at their school or institution and an aca15 demic advisor to assist in the completion of their 

16 baccalaureate degree. 

17 ‘‘(e) SCHOLARSHIPS.—The Secretary may approve 

18 payment of scholarships under this section for such indi19 viduals for any period of education in student under20 graduate tenure, except that such a scholarship may not 

21 be provided to an individual for more than 4 years, and 

22 such scholarships may not exceed $10,000 per academic 

23 year (notwithstanding any other provision of law regard24 ing the amount of scholarship). 


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1 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

2 is authorized to be appropriated to carry out this section 

3 such sums as may be necessary for each of fiscal years 

4 2019 through 2024. 

5 ‘‘SEC. 3420. PATSY MINK HEALTH AND GENDER RESEARCH 

6 FELLOWSHIP PROGRAM. 

7 ‘‘(a) IN GENERAL.—The Director of the Centers for 

8 Disease Control and Prevention, in collaboration with the 

9 Deputy Assistant Secretary for Minority Health, the Ad10 ministrator of the Substance Abuse and Mental Health 

11 Services Administration, and the Director of the Indian 

12 Health Services, shall award research fellowships to post13 baccalaureate students to conduct research that will exam14 ine gender and health disparities and to pursue a career 

15 in the health professions. 

16 ‘‘(b) ELIGIBILITY.—To be eligible to receive a fellow17 ship under subsection (a) an individual shall— 

18 ‘‘(1) have experience in health research or pub19 lic health practice; 

20 ‘‘(2) reside in a health professional shortage 

21 area as determined by the Secretary; 

22 ‘‘(3) have expressed an interest in the health 

23 professions; 

24 ‘‘(4) demonstrate promise for becoming a leader 

25 in the field of women’s health; 


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1 ‘‘(5) secure admission to a health professions 

2 school or graduate program with an emphasis in 

3 gender studies; 

4 ‘‘(6) comply with subsection (f); and 

5 ‘‘(7) submit to the Secretary an application at 

6 such time, in such manner, and containing such in7 formation as the Secretary may require. 

8 ‘‘(c) USE OF FUNDS.—Amounts received under an 

9 award under subsection (a) shall be used to support oppor10 tunities for students to become researchers and advance 

11 the research base on the intersection between gender and 

12 health. 

13 ‘‘(d) PRIORITY.—In awarding grants under sub14 section (a), the Director of the Centers for Disease Con15 trol and Prevention shall give priority to those applicants 

16 that— 

17 ‘‘(1) are from disadvantaged backgrounds; and 

18 ‘‘(2) have identified a mentor and academic ad19 visor who will assist in the completion of their grad20 uate or professional degree and have secured a re21 search assistant position with a researcher working 

22 in the area of gender and health. 

23 ‘‘(e) FELLOWSHIPS.—The Director of the Centers for 

24 Disease Control and Prevention may approve fellowships 

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1 cation in the student’s graduate or health profession ten2 ure, except that such a fellowship may not be provided 

3 to an individual for more than 3 years, and such a fellow4 ship may not exceed $18,000 per academic year (notwith5 standing any other provision of law regarding the amount 

6 of fellowship). 

7 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

8 is authorized to be appropriated to carry out this section 

9 such sums as may be necessary for each of fiscal years 

10 2019 through 2024. 

11 ‘‘SEC. 3420A. PAUL DAVID WELLSTONE INTERNATIONAL 

12 HEALTH FELLOWSHIP PROGRAM. 

13 ‘‘(a) IN GENERAL.—The Director of the Agency for 

14 Healthcare Research and Quality, in collaboration with 

15 the Deputy Assistant Secretary for Minority Health, shall 

16 award research fellowships to college students or recent 

17 graduates to advance their understanding of international 

18 health. 

19 ‘‘(b) ELIGIBILITY.—To be eligible to receive a fellow20 ship under subsection (a) an individual shall— 

21 ‘‘(1) have educational experience in the field of 

22 international health; 

23 ‘‘(2) reside in a health professional shortage 

24 area as determined by the Secretary; 


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1 ‘‘(3) demonstrate promise for becoming a leader 

2 in the field of international health; 

3 ‘‘(4) be a college senior or recent graduate of 

4 a four-year higher education institution; 

5 ‘‘(5) comply with subsection (e); and 

6 ‘‘(6) submit to the Secretary an application at 

7 such time, in such manner, and containing such in8 formation as the Secretary may require. 

9 ‘‘(c) USE OF FUNDS.—Amounts received under an 

10 award under subsection (a) shall be used to support oppor11 tunities for students to become health professionals and 

12 to advance their knowledge about international issues re13 lating to health care access and quality. 

14 ‘‘(d) PRIORITY.—In awarding grants under sub15 section (a), the Director shall give priority to those appli16 cants that— 

17 ‘‘(1) are from a disadvantaged background; and 

18 ‘‘(2) have identified a mentor at a health pro19 fessions school or institution, an academic advisor to 

20 assist in the completion of their graduate or profes21 sional degree, and an advisor from an international 

22 health non-governmental organization, private volun23 teer organization, or other international institution 

24 or program that focuses on increasing health care 


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1 access and quality for residents in developing coun2 tries. 

3 ‘‘(e) FELLOWSHIPS.—The Secretary shall approve 

4 fellowships for college seniors or recent graduates, except 

5 that such a fellowship may not be provided to an indi6 vidual for more than 6 months, may not be awarded to 

7 a graduate that has not been enrolled in school for more 

8 than 1 year, and may not exceed $4,000 per academic year 

9 (notwithstanding any other provision of law regarding the 

10 amount of fellowship). 

11 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

12 is authorized to be appropriated to carry out this section, 

13 such sums as may be necessary for each of fiscal years 

14 2019 through 2024. 

15 ‘‘SEC. 3420B. EDWARD R. ROYBAL HEALTH SCHOLAR PRO16 GRAM. 

17 ‘‘(a) IN GENERAL.—The Director of the Agency for 

18 Healthcare Research and Quality, the Director of the Cen19 ters for Medicare and Medicaid Services, and the Adminis20 trator for Health Resources and Services Administration, 

21 in collaboration with the Deputy Assistant Secretary for 

22 Minority Health, shall award grants to eligible entities to 

23 expose entering graduate students to the health profes24 sions. 


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

2 under subsection (a), an entity shall— 

3 ‘‘(1) be a clinical, public health, or health serv4 ices organization, community-based, academic, or 

5 nonprofit entity, or other entity determined appro6 priate by the Director of the Agency for Healthcare 

7 Research and Quality; 

8 ‘‘(2) serve in a health professional shortage 

9 area as determined by the Secretary; 

10 ‘‘(3) work with students obtaining a degree in 

11 the health professions; and 

12 ‘‘(4) submit to the Secretary an application at 

13 such time, in such manner, and containing such in14 formation as the Secretary may require. 

15 ‘‘(c) USE OF FUNDS.—Amounts received under a 

16 grant awarded under subsection (a) shall be used to sup17 port opportunities that expose students to non-research18 based health professions, including— 

19 ‘‘(1) public health policy; 

20 ‘‘(2) health care and pharmaceutical policy; 

21 ‘‘(3) health care administration and manage22 ment; 

23 ‘‘(4) health economics; and 

24 ‘‘(5) other professions determined appropriate 

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1 search and Quality, the Director of the Centers for 

2 Medicare and Medicaid Services, and the Adminis3 trator for Health Resources and Services Adminis4 tration. 

5 ‘‘(d) PRIORITY.—In awarding grants under sub6 section (a), the Director of the Agency for Healthcare Re7 search and Quality shall give priority to those entities 

8 that— 

9 ‘‘(1) have experience with health disparity elimi10 nation programs; 

11 ‘‘(2) facilitate training in the fields described in 

12 subsection (c); and 

13 ‘‘(3) provide counseling or other services de14 signed to assist such individuals in successfully com15 pleting their education at the postsecondary level. 

16 ‘‘(e) STIPENDS.—The Secretary may approve the 

17 payment of stipends for individuals under this section for 

18 any period of education in student-enhancement programs 

19 (other than regular courses) at health professions schools 

20 or entities, except that such a stipend may not be provided 

21 to an individual for more than 2 months, and such a sti22 pend may not exceed $100 per day (notwithstanding any 

23 other provision of law regarding the amount of stipends). 

24 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

25 is authorized to be appropriated to carry out this section 


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1 such sums as may be necessary for each of fiscal years 

2 2019 through 2024. 

3 ‘‘SEC. 3420C. LEADERSHIP FELLOWSHIP PROGRAMS. 

4 ‘‘The Secretary of Health and Human Services shall 

5 award grants to entities to develop leadership fellowship 

6 programs for underrepresented health professionals to be7 come future leaders in public health and health care deliv8 ery institutions.’’. 

9 SEC. 307. MCNAIR POSTBACCALAUREATE ACHIEVEMENT 

10 PROGRAM. 

11 Section 402E of the Higher Education Act of 1965 

12 (20 U.S.C. 1070a–15) is amended by striking subsection 

13 (g) and inserting the following: 

14 ‘‘(g) COLLABORATION IN HEALTH PROFESSION DI15 VERSITY TRAINING PROGRAMS.—The Secretary shall co16 ordinate with the Secretary of Health and Human Serv17 ices to ensure that there is collaboration between the goals 

18 of the program under this section and programs of the 

19 Health Resources and Services Administration that pro20 mote health workforce diversity. The Secretary of Edu21 cation shall take such measures as may be necessary to 

22 encourage students participating in projects assisted 

23 under this section to consider health profession careers. 

24 ‘‘(h) FUNDING.—From amounts appropriated pursu25 ant to the authority of section 402A(g), the Secretary 


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1 shall, to the extent practicable, allocate funds for projects 

2 authorized by this section in an amount which is not less 

3 than $31,000,000 for each of the fiscal years 2019 

4 through 2025.’’. 

5 SEC. 308. RULES FOR DETERMINATION OF FULL-TIME 

6 EQUIVALENT RESIDENTS FOR COST-REPORT7 ING PERIODS. 

8 (a) DGME DETERMINATIONS.—Section 1886(h)(4) 

9 of the Social Security Act (42 U.S.C. 1395ww(h)(4)), as 

10 amended by section 204(a), is amended— 

11 (1) in subparagraph (E), by striking ‘‘Subject 

12 to subparagraphs (J) and (K), such rules’’ and in13 serting ‘‘Subject to subparagraphs (J), (K), and 

14 (M), such rules’’; 

15 (2) in subparagraph (J), by striking ‘‘Such 

16 rules’’ and inserting ‘‘Subject to subparagraph (M), 

17 such rules’’; 

18 (3) in subparagraph (K), by striking ‘‘In deter19 mining’’ and inserting ‘‘Subject to subparagraph 

20 (M), in determining’’; and 

21 (4) by adding at the end the following new sub22 paragraph: 

23 ‘‘(M) TREATMENT OF CERTAIN RESIDENTS

24 AND INTERNS.—For purposes of cost-reporting 

25 periods beginning on or after October 1, 2016, 


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1 in determining the hospital’s number of full2 time equivalent residents for purposes of this 

3 paragraph, all the time spent by an intern or 

4 resident in an approved medical residency train5 ing program shall be counted toward the deter6 mination of full-time equivalency if the hos7 pital— 

8 ‘‘(i) is recognized as a subsection (d) 

9 hospital; 

10 ‘‘(ii) is recognized as a subsection (d) 

11 Puerto Rico hospital; 

12 ‘‘(iii) is reimbursed under a reim13 bursement system authorized under section 

14 1814(b)(3); or 

15 ‘‘(iv) is a provider-based hospital out16 patient department.’’. 

17 (b) IME DETERMINATIONS.—Section 

18 1886(d)(5)(B)(x) of the Social Security Act (42 U.S.C. 

19 1395ww(d)(5)(B)(x)) is amended— 

20 (1) in subclause (II), by striking ‘‘In deter21 mining’’ and inserting ‘‘Subject to subclause (IV), in 

22 determining’’; 

23 (2) in subclause (III), by striking ‘‘In deter24 mining’’ and inserting ‘‘Subject to subclause (IV), in 

25 determining’’; and 


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1 (3) by inserting after subclause (III) the fol2 lowing new subclause: 

3 ‘‘(IV) The provisions of subparagraph (L) 

4 of subsection (h)(4) shall apply under this sub5 paragraph in the same manner as they apply 

6 under such subsection.’’. 

7 SEC. 309. DEVELOPING AND IMPLEMENTING STRATEGIES 

8 FOR LOCAL HEALTH EQUITY. 

9 (a) GRANTS.—The Secretaries of Health and Human 

10 Services, Education, and Labor, acting jointly, shall make 

11 grants to academic institutions for the purposes of— 

12 (1) in accordance with subsection (b), devel13 oping capacity— 

14 (A) to build an evidence base for successful 

15 strategies for increasing local health equity; and 

16 (B) to serve as national models of driving 

17 local health equity; 

18 (2) in accordance with subsection (c), devel19 oping a strategic partnership with the community in 

20 which the academic institution is located; and 

21 (3) collecting data on, and periodically evalu22 ating, the effectiveness of the institution’s programs 

23 funded through this section to enable the institution 

24 to adapt accordingly for maximum efficiency and 

25 success. 


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1 (b) DEVELOPING CAPACITY FOR INCREASING LOCAL

2 HEALTH EQUITY.—As a condition on receipt of a grant 

3 under subsection (a), an academic institution shall agree 

4 to use the grant to build an evidence base for successful 

5 strategies for increasing local health equity, and to serve 

6 as a national model of driving local health equity, by sup7 porting— 

8 (1) resources to strengthen institutional metrics 

9 and capacity to execute institutionwide health work10 force goals that can serve as models for increasing 

11 health equity in communities across the country; 

12 (2) collaborations among a cohort of institu13 tions in implementing systemic change, partnership 

14 development, and programmatic efforts supportive of 

15 health equity goals across disciplines and popu16 lations; and 

17 (3) enhanced or newly developed data systems 

18 and research infrastructure capable of informing 

19 current and future workforce efforts and building a 

20 foundation for a broader research agenda targeting 

21 urban health disparities. 

22 (c) STRATEGIC PARTNERSHIPS.—As a condition on 

23 receipt of a grant under subsection (a), an academic insti24 tution shall agree to use the grant to develop a strategic 


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1 partnership with the community in which the institution 

2 is located for the purposes of— 

3 (1) strengthening connections between the insti4 tution and the community— 

5 (A) to improve evaluation of and address 

6 the community’s health and health workforce 

7 needs; and 

8 (B) to engage the community in health 

9 workforce development; 

10 (2) developing, enhancing, or accelerating inno11 vative undergraduate and graduate programs in the 

12 biomedical sciences and health professions; and 

13 (3) strengthening pipeline programs in the bio14 medical sciences and health professions, including by 

15 developing partnerships between institutions of high16 er education and elementary and secondary schools 

17 to recruit the next generation of health professionals 

18 earlier in the pipeline to a health care career. 

19 SEC. 310. LOAN FORGIVENESS FOR MENTAL AND BEHAV20 IORAL HEALTH SOCIAL WORKERS. 

21 Section 455 of the Higher Education Act of 1965 (20 

22 U.S.C. 1087e) is amended by adding at the end the fol23 lowing new subsection: 

24 ‘‘(r) REPAYMENT PLAN FOR MENTAL AND BEHAV25 IORAL HEALTH SOCIAL WORKERS.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall cancel 

2 the balance of interest and principal due on any eli3 gible Federal Direct Loan not in default for a bor4 rower who— 

5 ‘‘(A) has made 120 monthly payments on 

6 the eligible Federal Direct Loan after October 

7 1, 2016, pursuant to any one or a combination 

8 of the following— 

9 ‘‘(i) payments under an income-based 

10 repayment plan under section 493C; 

11 ‘‘(ii) payments under a standard re12 payment plan under subsection (d)(1)(A), 

13 based on a 10-year repayment period; 

14 ‘‘(iii) monthly payments under a re15 payment plan under subsection (d)(1) or 

16 (g) of not less than the monthly amount 

17 calculated under subsection (d)(1)(A), 

18 based on a 10-year repayment period; or 

19 ‘‘(iv) payments under an income con20 tingent repayment plan under subsection 

21 (d)(1)(D); and 

22 ‘‘(B)(i) is employed as a mental health or 

23 behavioral health social worker, as defined by 

24 the Secretary by regulation, at the time of such 

25 forgiveness; and 


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1 ‘‘(ii) has been employed as such a mental 

2 health or behavioral health social worker during 

3 the period in which the borrower makes each of 

4 the 120 payments as described in subparagraph 

5 (A). 

6 ‘‘(2) LOAN CANCELLATION AMOUNT.—After the 

7 conclusion of the employment period described in 

8 paragraph (1), the Secretary shall cancel the obliga9 tion to repay the balance of principal and interest 

10 due as of the time of such cancellation, on the eligi11 ble Federal Direct Loans made to the borrower 

12 under this part. 

13 ‘‘(3) INELIGIBILITY FOR DOUBLE BENEFITS.— 

14 No borrower may, for the same employment as a 

15 mental health or behavioral health social worker, re16 ceive a reduction of loan obligations under both this 

17 subsection and subsection (m), 428J, 428K, 428L, 

18 or 460. 

19 ‘‘(4) DEFINITION OF ELIGIBLE FEDERAL DI20 RECT LOAN.—In this subsection, the term ‘eligible 

21 Federal Direct Loan’ means a Federal Direct Staf22 ford Loan, Federal Direct PLUS Loan, Federal Di23 rect Unsubsidized Stafford Loan, or a Federal Di24 rect Consolidation Loan.’’. 


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1 SEC. 311. HEALTH PROFESSIONS WORKFORCE FUND. 

2 (a) PURPOSE.—It is the purpose of this section to 

3 establish a Health Professions Workforce Fund to be ad4 ministered through the Health Resources and Services Ad5 ministration within the Department of Health and Human 

6 Services to provide for expanded and sustained national 

7 investment in the health professions and nursing work8 force development programs under title VII and title VIII 

9 of the Public Health Service Act. 

10 (b) ESTABLISHING THE HEALTH PROFESSIONS

11 WORKFORCE FUND.—There is authorized to be appro12 priated, and there is appropriated, out of any monies in 

13 the Treasury not otherwise appropriated, to the Health 

14 Professions Workforce Fund— 

15 (1) $355,000,000 for fiscal year 2019; 

16 (2) $375,000,000 for fiscal year 2020; 

17 (3) $392,000,000 for fiscal year 2021; 

18 (4) $412,000,000 for fiscal year 2022; 

19 (5) $432,000,000 for fiscal year 2023; 

20 (6) $454,000,000 for fiscal year 2024; 

21 (7) $476,000,000 for fiscal year 2025; 

22 (8) $500,000,000 for fiscal year 2026; 

23 (9) $525,000,000 for fiscal year 2027; and 

24 (10) $552,000,000 for fiscal year 2028. 

25 (c) FUNDING.— 


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1 (1) For the purpose of carrying out health pro2 fessions education programs authorized under title 

3 VII of the Public Health Service Act, in addition to 

4 any other amounts authorized to be appropriated for 

5 such purpose, there is authorized to be appropriated 

6 out of any monies in the Health Professions Work7 force Fund, the following: 

8 (A) $240,000,000 for fiscal year 2019. 

9 (B) $253,000,000 for fiscal year 2020. 

10 (C) $265,000,000 for fiscal year 2021. 

11 (D) $278,000,000 for fiscal year 2022. 

12 (E) $292,000,000 for fiscal year 2023. 

13 (F) $307,000,000 for fiscal year 2024. 

14 (G) $322,000,000 for fiscal year 2025. 

15 (H) $338,000,000 for fiscal year 2026. 

16 (I) $355,000,000 for fiscal year 2027. 

17 (J) $373,000,000 for fiscal year 2028. 

18 (2) For the purpose of carrying out nursing 

19 workforce development programs authorized under 

20 Title VIII of the Public Health Service Act, in addi21 tion to any other amounts authorized to be appro22 priated for such purpose, there is authorized to be 

23 appropriated out of any monies in the Health Pro24 fessions Workforce Fund, the following: 

25 (A) $115,000,000 for fiscal year 2019. 


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1 (B) $122,000,000 for fiscal year 2020. 

2 (C) $127,000,000 for fiscal year 2021. 

3 (D) $134,000,000 for fiscal year 2022. 

4 (E) $140,000,000 for fiscal year 2023. 

5 (F) $147,000,000 for fiscal year 2024. 

6 (G) $154,000,000 for fiscal year 2025. 

7 (H) $162,000,000 for fiscal year 2026. 

8 (I) $170,000,000 for fiscal year 2027. 

9 (J) $179,000,000 for fiscal year 2028. 

10 SEC. 312. FINDINGS; SENSE OF CONGRESS RELATING TO 

11 GRADUATE MEDICAL EDUCATION. 

12 (a) FINDINGS.—Congress finds the following: 

13 (1) Projections by the Association of American 

14 Medical Colleges (AAMC) and other expert entities, 

15 such as the Health Resources and Services Adminis16 tration (HRSA), have indicated a nationwide short17 age of up to 104,900 physicians, split evenly be18 tween primary care and specialists, by 2030. 

19 (2) Primarily due to the growing and aging 

20 population, over the next decade, physician demand 

21 is expected to grow up to 17 percent. 

22 (3) The United States Census Bureau estimates 

23 that the United States population will grow from 

24 321 million in 2015 to 347 million in 2025. Further, 

25 the number of Medicare beneficiaries is estimated to 


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1 increase from 47.8 million in 2015 to approximately 

2 66 million in 2025. 

3 (4) Approximately 36 percent of practicing phy4 sicians are over the age of 55 and are likely to retire 

5 within the next decade. 

6 (5) A nationwide physician shortage will result 

7 in many Americans waiting longer and traveling far8 ther for health care; seeking nonemergent care in 

9 emergency departments; and delaying treatment 

10 until their health care needs become more serious, 

11 complex, and costly. 

12 (6) Changing demographics (such as an aging 

13 population), new health care delivery models (such 

14 as medical homes), and other factors (such as dis15 aster preparedness) are contributing to a shortage of 

16 both generalist and specialist physicians. 

17 (7) These shortages will have the most severe 

18 impact on vulnerable and underserved populations, 

19 including racial/ethnic minorities and the approxi20 mately 20 percent of Americans who live in rural or 

21 inner-city locations designated as health professional 

22 shortage areas. 

23 (8) The AAMC’s Health Care Utilization Eq24 uity model estimates that if racial and ethnic minori25 ties and individuals from rural areas utilized health 


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1 care in a similar way to their Caucasian counter2 parts living in metropolitan areas, the physician 

3 shortage would require an additional 96,000 physi4 cians. 

5 (9) To address the physician shortage, medical 

6 education and training need to be accessible for stu7 dents and physicians from all backgrounds. Inter8 national graduates play an important role in U.S. 

9 health care, representing roughly 25 percent of the 

10 health care workforce. Immigration pathways like 

11 student, exchange-visitor, and employment visas, and 

12 programs like the National Interest Waiver and 

13 Conrad 30 J–1 Visa Waiver, help improve health ac14 cess across the country. 

15 (10) United States medical schools have com16 mitted to and have initiated a 30 percent increase 

17 in enrollment by 2017 to help reduce the Nation’s 

18 shortage of quality physicians. 

19 (11) An increase in United States medical 

20 school graduates must be accompanied by an in21 crease of 4,000 graduate medical education (GME) 

22 training positions each year. 

23 (12) Graduate medical education programs and 

24 teaching hospitals provide venues in which the next 

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1 ratively with other physicians and health profes2 sionals, adopt more efficient care delivery models 

3 (such as care coordination and medical homes), in4 corporate health information technology and elec5 tronic health records in every aspect of their work, 

6 apply new methods of assuring quality and safety, 

7 and participate in groundbreaking clinical and public 

8 health research. 

9 (13) The Medicare Program under title XVIII 

10 of the Social Security Act (having more beneficiaries 

11 than any other health care program), supports its 

12 ‘‘fair share’’ of the costs associated with graduate 

13 medical education (GME). 

14 (14) In general, the level of support of graduate 

15 medical education by the Medicare Program has 

16 been capped since 1997 and has not been increased 

17 to support the expansion of graduate medical edu18 cation programs needed to avert the projected physi19 cian shortage or to accommodate the increase in 

20 United States medical school graduates. 

21 (b) SENSE OF CONGRESS.—It is the sense of Con22 gress that eliminating the limit of the number of residency 

23 positions that receive some level of Medicare support 

24 under section 1886(h) of the Social Security Act (42 


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1 U.S.C. 1395ww(h)), also referred to as the Medical grad2 uate medical education cap, is critical to— 

3 (1) ensuring an appropriate supply of physi4 cians to meet the Nation’s health care needs; 

5 (2) facilitating equitable access for all who seek 

6 health care; and 

7 (3) mitigating disparities in health and health 

8 care. 

9 SEC. 313. CAREER SUPPORT FOR SKILLED, INTERNATION10 ALLY EDUCATED HEALTH PROFESSIONALS. 

11 (a) FINDINGS.—Congress finds the following: 

12 (1) According to the Association of Schools of 

13 Public Health, projections indicate a nationwide 

14 shortage of up to 250,000 public health workers 

15 needed by 2020. 

16 (2) Similar trends are projected for other health 

17 professions indicating shortages across disciplines, 

18 including within the fields of nursing (500,000 by 

19 2025), dentistry (15,000 by 2025), pharmacy 

20 (38,000 by 2030), mental and behavioral health, pri21 mary care (46,000 by 2025), and community and al22 lied health. 

23 (3) A nationwide health workforce shortage will 

24 result in serious health threats and more severe and 

25 costly health care needs, due to, in part, a delayed 


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1 response to food-borne outbreaks, emerging infec2 tious diseases, natural disasters, fewer cancer 

3 screenings, and delayed treatment. 

4 (4) Vulnerable and underserved populations and 

5 health professional shortage areas will be most se6 verely impacted by the health workforce shortage. 

7 (5) According to the Migration Policy Institute, 

8 over 2,000,000 college-educated immigrants in the 

9 United States today are unemployed or under10 employed in low- or semi-skilled jobs that fail to 

11 draw on their education and expertise. 

12 (6) Approximately 2 out of every 5 internation13 ally educated immigrants are unemployed or under14 employed. 

15 (7) According to Drexel University Center for 

16 Labor Markets and Policy, underemployment for 

17 internationally educated immigrant women is 28 per18 cent higher than for their male counterparts. 

19 (8) According to the Drexel University Center 

20 for labor markets and policy, the mean annual earn21 ings of underemployed immigrants were $32,000, or 

22 43 percent less than United States born college 

23 graduates employed in the college labor market. 

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1 port, underemployed skilled immigrants typically in2 crease their income by 215 percent to 900 percent. 

3 (10) According to the Brookings Institution and 

4 the Partnership for a New American Economy, im5 migrants working in the health workforce are, on av6 erage, better educated than United States-born 

7 workers in the health workforce. 

8 (b) GRANTS TO ELIGIBLE ENTITIES.— 

9 (1) AUTHORITY TO PROVIDE GRANTS.—The 

10 Secretary of Health and Human Services acting 

11 through the Bureau of Health Workforce within the 

12 Health Resources and Services Administration, the 

13 National Institute on Minority Health and Health 

14 Disparities, or the Office of Minority Health (in this 

15 section referred to as the ‘‘Secretary’’) may award 

16 grants to eligible entities to carry out activities de17 scribed in subsection (c). 

18 (2) ELIGIBILITY.—To be eligible to receive a 

19 grant under this section, an entity shall— 

20 (A) be a clinical, public health, or health 

21 services organization, a community-based or 

22 nonprofit entity, an academic institution, a 

23 faith-based organization, a State, county, or 

24 local government, an Area Health Education 


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1 Center, or another entity determined appro2 priate by the Secretary; and 

3 (B) submit to the Secretary an application 

4 at such time, in such manner, and containing 

5 such information as the Secretary may require. 

6 (c) AUTHORIZED ACTIVITIES.—A grant awarded 

7 under this section shall be used— 

8 (1) to provide services to assist unemployed and 

9 underemployed skilled immigrants, residing in the 

10 United States, who have legal, permanent work au11 thorization and who are internationally educated 

12 health professionals, enter into the American health 

13 workforce with employment matching their health 

14 professional skills and education, and advance in em15 ployment to positions that better match their health 

16 professional education and expertise; 

17 (2) to provide training opportunities to reduce 

18 barriers to entry and advancement in the health 

19 workforce for skilled, internationally educated immi20 grants; 

21 (3) to educate employers regarding the abilities 

22 and capacities of internationally educated health 

23 professionals; 

24 (4) to assist in the evaluation of foreign creden25 tials; 


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1 (5) to support preceptorships for international 

2 medical graduates in hospital primary care training; 

3 and 

4 (6) to facilitate access to contextualized and ac5 celerated courses on English as a second language. 

6 TITLE IV—IMPROVING HEALTH 

7 CARE ACCESS AND QUALITY 

8 Subtitle A—Expansion of Coverage 

9 SEC. 401. AMENDMENT TO THE PUBLIC HEALTH SERVICE 

10 ACT. 

11 Title XXXIV of the Public Health Service Act, as 

12 amended by titles I, II, III, and IX of this Act, is further 

13 amended by inserting after subtitle C the following: 

14 ‘‘Subtitle D—Reconstruction and 

15 Improvement Grants for Public 

16 Health Care Facilities Serving 

17 Pacific Islanders and the Insu18 lar Areas 

19 ‘‘SEC. 3451. GRANT SUPPORT FOR QUALITY IMPROVEMENT 

20 INITIATIVES. 

21 ‘‘(a) IN GENERAL.—The Secretary, in collaboration 

22 with the Administrator of the Health Resources and Serv23 ices Administration, the Director of the Agency for 

24 Healthcare Research and Quality, and the Administrator 

25 of the Centers for Medicare & Medicaid Services, shall 


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1 award grants to eligible entities for the conduct of dem2 onstration projects to improve the quality of and access 

3 to health care. 

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

5 under subsection (a), an entity shall— 

6 ‘‘(1) be a health center, hospital, health plan, 

7 health system, community clinic. or other health en8 tity determined appropriate by the Secretary— 

9 ‘‘(A) that, by legal mandate or explicitly 

10 adopted mission, provides patients with access 

11 to services regardless of their ability to pay; 

12 ‘‘(B) that provides care or treatment for a 

13 substantial number of patients who are unin14 sured, are receiving assistance under a State 

15 program under title XIX of the Social Security 

16 Act, or are members of vulnerable populations, 

17 as determined by the Secretary; and 

18 ‘‘(C)(i) with respect to which, not less than 

19 50 percent of the entity’s patient population is 

20 made up of racial and ethnic minorities; or 

21 ‘‘(ii) that— 

22 ‘‘(I) serves a disproportionate percent23 age of local, minority racial and ethnic pa24 tients, or that has a patient population, at 


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1 least 50 percent of which is limited2 English-proficient; and 

3 ‘‘(II) provides an assurance that 

4 amounts received under the grant will be 

5 used only to support quality improvement 

6 activities in the racial and ethnic popu7 lation served; and 

8 ‘‘(2) prepare and submit to the Secretary an 

9 application at such time, in such manner, and con10 taining such information as the Secretary may re11 quire. 

12 ‘‘(c) PRIORITY.—In awarding grants under sub13 section (a), the Secretary shall give priority to applicants 

14 under subsection (b)(2) that— 

15 ‘‘(1) demonstrate an intent to operate as part 

16 of a health care partnership, network, collaborative, 

17 coalition, or alliance where each member entity con18 tributes to the design, implementation, and evalua19 tion of the proposed intervention; or 

20 ‘‘(2) intend to use funds to carry out system21 wide changes with respect to health care quality im22 provement, including— 

23 ‘‘(A) improved systems for data collection 

24 and reporting; 


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1 ‘‘(B) innovative collaborative or similar 

2 processes; 

3 ‘‘(C) group programs with behavioral or 

4 self-management interventions; 

5 ‘‘(D) case management services; 

6 ‘‘(E) physician or patient reminder sys7 tems; 

8 ‘‘(F) educational interventions; or 

9 ‘‘(G) other activities determined appro10 priate by the Secretary. 

11 ‘‘(d) USE OF FUNDS.—An entity shall use amounts 

12 received under a grant under subsection (a) to support 

13 the implementation and evaluation of health care quality 

14 improvement activities or minority health and health care 

15 disparity reduction activities that include— 

16 ‘‘(1) with respect to health care systems, activi17 ties relating to improving— 

18 ‘‘(A) patient safety; 

19 ‘‘(B) timeliness of care; 

20 ‘‘(C) effectiveness of care; 

21 ‘‘(D) efficiency of care; 

22 ‘‘(E) patient centeredness; and 

23 ‘‘(F) health information technology; and 

24 ‘‘(2) with respect to patients, activities relating 

25 to— 


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1 ‘‘(A) staying healthy; 

2 ‘‘(B) getting well, mentally and physically; 

3 ‘‘(C) living effectively with illness or dis4 ability; 

5 ‘‘(D) coping with end-of-life issues; and 

6 ‘‘(E) shared decisionmaking. 

7 ‘‘(e) COMMON DATA SYSTEMS.—The Secretary shall 

8 provide financial and other technical assistance to grant9 ees under this section for the development of common data 

10 systems. 

11 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

12 are authorized to be appropriated to carry out this section 

13 such sums as may be necessary for each of fiscal years 

14 2019 through 2024. 

15 ‘‘SEC. 3452. CENTERS OF EXCELLENCE. 

16 ‘‘(a) IN GENERAL.—The Secretary, acting through 

17 the Administrator of the Health Resources and Services 

18 Administration, shall designate centers of excellence at 

19 public hospitals, and other health systems serving large 

20 numbers of minority patients, that— 

21 ‘‘(1) meet the requirements of section 

22 3451(b)(1); 

23 ‘‘(2) demonstrate excellence in providing care to 

24 minority populations; and 


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1 ‘‘(3) demonstrate excellence in reducing dispari2 ties in health and health care. 

3 ‘‘(b) REQUIREMENTS.—A hospital or health system 

4 that serves as a center of excellence under subsection (a) 

5 shall— 

6 ‘‘(1) design, implement, and evaluate programs 

7 and policies relating to the delivery of care in ra8 cially, ethnically, and linguistically diverse popu9 lations; 

10 ‘‘(2) provide training and technical assistance 

11 to other hospitals and health systems relating to the 

12 provision of quality health care to minority popu13 lations; and 

14 ‘‘(3) develop activities for graduate or con15 tinuing medical education that institutionalize a 

16 focus on cultural competence training for health care 

17 providers. 

18 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There 

19 are authorized to be appropriated to carry out this section, 

20 such sums as may be necessary for each of fiscal years 

21 2019 through 2024. 


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1 ‘‘SEC. 3453. RECONSTRUCTION AND IMPROVEMENT GRANTS 

2 FOR PUBLIC HEALTH CARE FACILITIES SERV3 ING PACIFIC ISLANDERS AND THE INSULAR 

4 AREAS. 

5 ‘‘(a) IN GENERAL.—The Secretary shall provide di6 rect financial assistance to designated health care pro7 viders and community health centers in American Samoa, 

8 Guam, the Commonwealth of the Northern Mariana Is9 lands, the United States Virgin Islands, Puerto Rico, and 

10 Hawaii for the purposes of reconstructing and improving 

11 health care facilities and services in a culturally competent 

12 and sustainable manner. 

13 ‘‘(b) ELIGIBILITY.—To be eligible to receive direct fi14 nancial assistance under subsection (a), an entity shall be 

15 a public health facility or community health center located 

16 in American Samoa, Guam, the Commonwealth of the 

17 Northern Mariana Islands, the United States Virgin Is18 lands, Puerto Rico, or Hawaii that— 

19 ‘‘(1) is owned or operated by— 

20 ‘‘(A) the Government of American Samoa, 

21 Guam, the Commonwealth of the Northern 

22 Mariana Islands, the United States Virgin Is23 lands, Puerto Rico, or Hawaii or a unit of local 

24 government; or 

25 ‘‘(B) a nonprofit organization; and 


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1 ‘‘(2)(A) provides care or treatment for a sub2 stantial number of patients who are uninsured, re3 ceiving assistance under a State program under a 

4 title XVIII of the Social Security Act, or a State 

5 program under title XIX of such Act, or who are 

6 members of a vulnerable population, as determined 

7 by the Secretary; or 

8 ‘‘(B) serves a disproportionate percentage of 

9 local, minority racial and ethnic patients. 

10 ‘‘(c) REPORT.—Not later than 180 days after the 

11 date of enactment of this title and annually thereafter, the 

12 Secretary shall submit to the Congress and the President 

13 a report that includes an assessment of health resources 

14 and facilities serving populations in American Samoa, 

15 Guam, the Commonwealth of the Northern Mariana Is16 lands, the United States Virgin Islands, Puerto Rico, and 

17 Hawaii. In preparing such report, the Secretary shall— 

18 ‘‘(1) consult with and obtain information on all 

19 health care facilities needs from the entities de20 scribed in subsection (b); 

21 ‘‘(2) include all amounts of Federal assistance 

22 received by each entity in the preceding fiscal year; 

23 ‘‘(3) review the total unmet needs of each juris24 diction for health care facilities, including needs for 

25 renovation and expansion of existing facilities; 


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1 ‘‘(4) include a strategic plan for addressing the 

2 needs of each jurisdiction identified in the report; 

3 and 

4 ‘‘(5) evaluate the effectiveness of the care pro5 vided by measuring patient outcomes and cost meas6 ures. 

7 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

8 are authorized to be appropriated such sums as necessary 

9 to carry out this section.’’. 

10 SEC. 402. REMOVING CITIZENSHIP AND IMMIGRATION BAR11 RIERS TO ACCESS TO AFFORDABLE HEALTH 

12 CARE UNDER ACA. 

13 (a) IN GENERAL.— 

14 (1) PREMIUM TAX CREDITS.—Section 36B of 

15 the Internal Revenue Code of 1986 is amended— 

16 (A) in subsection (c)(1)(B)— 

17 (i) by amending the heading to read 

18 as follows: ‘‘SPECIAL RULE FOR CERTAIN

19 INDIVIDUALS INELIGIBLE FOR MEDICAID

20 DUE TO STATUS’’, and 

21 (ii) in clause (ii), by striking ‘‘lawfully 

22 present in the United States, but’’ and in23 serting ‘‘who’’, and 

24 (B) by striking subsection (e). 


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1 (2) COST-SHARING REDUCTIONS.—Section 1402 

2 of the Patient Protection and Affordable Care Act 

3 (42 U.S.C. 18071) is amended by striking sub4 section (e). 

5 (3) BASIC HEALTH PROGRAM ELIGIBILITY.— 

6 Section 1331(e)(1)(B) of the Patient Protection and 

7 Affordable Care Act (42 U.S.C. 18051(e)(1)(B)) is 

8 amended by striking ‘‘lawfully present in the United 

9 States’’. 

10 (4) RESTRICTIONS ON FEDERAL PAYMENTS.— 

11 Section 1412 of the Patient Protection and Afford12 able Care Act (42 U.S.C. 18082) is amended by 

13 striking subsection (d). 

14 (5) REQUIREMENT TO MAINTAIN MINIMUM ES15 SENTIAL COVERAGE.—Section 5000A(d) of the In16 ternal Revenue Code of 1986 is amended by striking 

17 paragraph (3) and by redesignating paragraph (4) 

18 as paragraph (3). 

19 (b) CONFORMING AMENDMENTS.— 

20 (1) Section 1411(a) of the Patient Protection 

21 and Affordable Care Act (42 U.S.C. 18081(a)) is 

22 amended by striking paragraph (1) and redesig23 nating paragraphs (2), (3), and (4) as paragraphs 

24 (1), (2), and (3), respectively. 


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1 (2) Section 1312(f) of the Patient Protection 

2 and Affordable Care Act (42 U.S.C. 18032(f)) is 

3 amended— 

4 (A) in the heading, by striking ‘‘; ACCESS

5 LIMITED TO CITIZENS AND LAWFUL RESI6 DENTS’’; and 

7 (B) by striking paragraph (3). 

8 SEC. 403. STUDY ON THE UNINSURED. 

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

10 Human Services (in this section referred to as the ‘‘Sec11 retary’’) shall— 

12 (1) conduct a study, in accordance with the 

13 standards under section 3101 of the Public Health 

14 Service Act (42 U.S.C. 300kk), on the demographic 

15 characteristics of the population of individuals who 

16 do not have health insurance coverage or oral health 

17 coverage; and 

18 (2) predict, based on such study, the demo19 graphic characteristics of the population of individ20 uals who would remain without health insurance cov21 erage after the end of any annual open enrollment 

22 or any special enrollment period or upon enactment 

23 and implementation of any legislative changes to the 

24 Patient Protection and Affordable Care Act that af25 fect the number of persons eligible for coverage. 


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1 (b) REPORTING REQUIREMENTS.— 

2 (1) IN GENERAL.—Not later than 12 months 

3 after the date of the enactment of this Act, the Sec4 retary shall submit to the Congress the results of 

5 the study under subsection (a)(1) and the prediction 

6 made under subsection (a)(2). 

7 (2) REPORTING OF DEMOGRAPHIC CHARACTER8 ISTICS.—The Secretary shall— 

9 (A) report the demographic characteristics 

10 under paragraphs (1) and (2) of subsection (a) 

11 on the basis of racial and ethnic group, and 

12 shall stratify the reporting on each racial and 

13 ethnic group by other demographic characteris14 tics that can impact access to health insurance 

15 coverage, such as sexual orientation, gender 

16 identity, primary language, disability status, 

17 sex, socioeconomic status, age group, and citi18 zenship and immigration status, in a manner 

19 consistent with title I of this Act; and 

20 (B) not use such report to engage in or an21 ticipate any deportation or immigration related 

22 enforcement action by any entity, including the 

23 Department of Homeland Security. 


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1 SEC. 404. MEDICAID IN THE TERRITORIES. 

2 (a) ELIMINATION OF GENERAL MEDICAID FUNDING

3 LIMITATIONS (‘‘CAP’’) FOR TERRITORIES.— 

4 (1) IN GENERAL.—Section 1108 of the Social 

5 Security Act (42 U.S.C. 1308) is amended— 

6 (A) in subsection (f), in the matter before 

7 paragraph (1), by striking ‘‘subsection (g)’’ and 

8 inserting ‘‘subsections (g) and (h)’’; 

9 (B) in subsection (g)(2), in the matter be10 fore subparagraph (A), by inserting ‘‘and sub11 section (h)’’ after ‘‘paragraphs (3) and (5)’’; 

12 and 

13 (C) by adding at the end the following new 

14 subsection: 

15 ‘‘(h) SUNSET OF MEDICAID FUNDING LIMITATIONS

16 FOR PUERTO RICO, THE VIRGIN ISLANDS OF THE

17 UNITED STATES, GUAM, THE NORTHERN MARIANA IS18 LANDS, AND AMERICAN SAMOA.—Subsections (f) and (g) 

19 shall not apply to Puerto Rico, the Virgin Islands of the 

20 United States, Guam, the Northern Mariana Islands, and 

21 American Samoa beginning with fiscal year 2019.’’. 

22 (2) CONFORMING AMENDMENTS.— 

23 (A) Section 1902(j) of the Social Security 

24 Act (42 U.S.C. 1396a(j)) is amended by strik25 ing ‘‘, the limitation in section 1108(f),’’. 


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1 (B) Section 1903(u) of the Social Security 

2 Act (42 U.S.C. 1396b(u)) is amended by strik3 ing paragraph (4). 

4 (C) Section 1323(c)(1) of the Patient Pro5 tection and Affordable Care Act (42 U.S.C. 

6 18043(c)(1)) is amended by striking ‘‘2019’’ 

7 and inserting ‘‘2018’’. 

8 (3) EFFECTIVE DATE.—The amendments made 

9 by this section shall apply beginning with fiscal year 

10 2019. 

11 (b) ELIMINATION OF SPECIFIC FEDERAL MEDICAL

12 ASSISTANCE PERCENTAGE (FMAP) LIMITATION FOR

13 TERRITORIES.—Section 1905(b) of the Social Security 

14 Act (42 U.S.C. 1396d(b)) is amended, in clause (2), by 

15 inserting ‘‘for fiscal years before fiscal year 2019’’ after 

16 ‘‘American Samoa’’. 

17 (c) APPLICATION OF MEDICAID WAIVER AUTHORITY

18 TO ALL OF THE TERRITORIES.— 

19 (1) IN GENERAL.—Section 1902(j) of the Social 

20 Security Act (42 U.S.C. 1396a(j)) is amended— 

21 (A) by striking ‘‘American Samoa and the 

22 Northern Mariana Islands’’ and inserting 

23 ‘‘Puerto Rico, the Virgin Islands of the United 

24 States, Guam, the Northern Mariana Islands, 

25 and American Samoa’’; 


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1 (B) by striking ‘‘American Samoa or the 

2 Northern Mariana Islands’’ and inserting 

3 ‘‘Puerto Rico, the Virgin Islands of the United 

4 States, Guam, the Northern Mariana Islands, 

5 or American Samoa’’; 

6 (C) by inserting ‘‘(1)’’ after ‘‘(j)’’; 

7 (D) by inserting ‘‘except as otherwise pro8 vided in this subsection,’’ after ‘‘Notwith9 standing any other requirement of this title’’; 

10 and 

11 (E) by adding at the end the following: 

12 ‘‘(2) The Secretary may not waive under this sub13 section the requirement of subsection (a)(10)(A)(i)(IX) 

14 (relating to coverage of adults formerly under foster care) 

15 with respect to any territory.’’. 

16 (2) EFFECTIVE DATE.—The amendments made 

17 by this section shall apply beginning October 1, 

18 2018. 

19 (d) PERMITTING MEDICAID DSH ALLOTMENTS FOR

20 TERRITORIES.—Section 1923(f) of the Social Security Act 

21 (42 U.S.C. 1396) is amended— 

22 (1) in paragraph (6), by adding at the end the 

23 following new subparagraph: 

24 ‘‘(C) TERRITORIES.— 


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1 ‘‘(i) FISCAL YEAR 2019.—For fiscal 

2 year 2019, the DSH allotment for Puerto 

3 Rico, the Virgin Islands of the United 

4 States, Guam, the Northern Mariana Is5 lands, and American Samoa shall bear the 

6 same ratio to $150,000,000 as the ratio of 

7 the number of individuals who are low-in8 come or uninsured and residing in such re9 spective territory (as estimated from time 

10 to time by the Secretary) bears to the 

11 sums of the number of such individuals re12 siding in all of the territories. 

13 ‘‘(ii) SUBSEQUENT FISCAL YEAR.— 

14 For each subsequent fiscal year, the DSH 

15 allotment for each such territory is subject 

16 to an increase in accordance with para17 graph (2).’’; and 

18 (2) in paragraph (9), by inserting before the pe19 riod at the end the following: ‘‘, and includes, begin20 ning with fiscal year 2019, Puerto Rico, the Virgin 

21 Islands of the United States, Guam, the Northern 

22 Mariana Islands, and American Samoa’’. 


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1 SEC. 405. EXTENSION OF MEDICARE SECONDARY PAYER. 

2 (a) IN GENERAL.—Section 1862(b)(1)(C) of the So3 cial Security Act (42 U.S.C. 1395y(b)(1)(C)) is amend4 ed— 

5 (1) in the last sentence, by inserting ‘‘, and be6 fore January 1, 2019’’ after ‘‘prior to such date)’’; 

7 and 

8 (2) by adding at the end the following new sen9 tence: ‘‘Effective for items and services furnished on 

10 or after January 1, 2019 (with respect to periods 

11 beginning on or after the date that is 42 months 

12 prior to such date), clauses (i) and (ii) shall be ap13 plied by substituting ‘42-month’ for ‘12-month’ each 

14 place it appears in the first sentence.’’. 

15 (b) EFFECTIVE DATE.—The amendments made by 

16 this section shall take effect on the date of enactment of 

17 this Act. For purposes of determining an individual’s sta18 tus under section 1862(b)(1)(C) of the Social Security Act 

19 (42 U.S.C. 1395y(b)(1)(C)), as amended by subsection 

20 (a), an individual who is within the coordinating period 

21 as of the date of enactment of this Act shall have that 

22 period extended to the full 42 months described in the last 

23 sentence of such section, as added by the amendment 

24 made by subsection (a)(2). 


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1 SEC. 406. BORDER HEALTH GRANTS. 

2 (a) ELIGIBLE ENTITY DEFINED.—In this section, 

3 the term ‘‘eligible entity’’ means a State, public institution 

4 of higher education, local government, Tribal government, 

5 nonprofit health organization, community health center, or 

6 community clinic receiving assistance under section 330 

7 of the Public Health Service Act (42 U.S.C. 254b), that 

8 is located in the border area. 

9 (b) AUTHORIZATION.—From funds appropriated 

10 under subsection (f), the Secretary of Health and Human 

11 Services (in this section referred to as the ‘‘Secretary’’), 

12 acting through the United States members of the United 

13 States-Mexico Border Health Commission, shall award 

14 grants to eligible entities to address priorities and rec15 ommendations to improve the health of border area resi16 dents that are established by— 

17 (1) the United States members of the United 

18 States-Mexico Border Health Commission; 

19 (2) the State border health offices; and 

20 (3) the Secretary. 

21 (c) APPLICATION.—An eligible entity that desires a 

22 grant under subsection (b) shall submit an application to 

23 the Secretary at such time, in such manner, and con24 taining such information as the Secretary may require. 


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1 (d) USE OF FUNDS.—An eligible entity that receives 

2 a grant under subsection (b) shall use the grant funds 

3 for— 

4 (1) programs relating to— 

5 (A) maternal and child health; 

6 (B) primary care and preventative health; 

7 (C) public health and public health infra8 structure; 

9 (D) musculoskeletal health and obesity; 

10 (E) health education and promotion; 

11 (F) oral health; 

12 (G) mental and behavioral health; 

13 (H) substance abuse; 

14 (I) health conditions that have a high prev15 alence in the border area; 

16 (J) medical and health services research; 

17 (K) workforce training and development; 

18 (L) community health workers, patient 

19 navigators, and promotoras; 

20 (M) health care infrastructure problems in 

21 the border area (including planning and con22 struction grants); 

23 (N) health disparities in the border area; 

24 (O) environmental health; and 


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1 (P) outreach and enrollment services with 

2 respect to Federal programs (including pro3 grams authorized under titles XIX and XXI of 

4 the Social Security Act (42 U.S.C. 1396 and 

5 1397aa)); and 

6 (2) other programs determined appropriate by 

7 the Secretary. 

8 (e) SUPPLEMENT, NOT SUPPLANT.—Amounts pro9 vided to an eligible entity awarded a grant under sub10 section (b) shall be used to supplement and not supplant 

11 other funds available to the eligible entity to carry out the 

12 activities described in subsection (d). 

13 (f) AUTHORIZATION OF APPROPRIATIONS.—There 

14 are authorized to be appropriated to carry out this section, 

15 $200,000,000 for fiscal year 2019, and such sums as may 

16 be necessary for each succeeding fiscal year. 

17 SEC. 407. REMOVING MEDICARE BARRIER TO HEALTH 

18 CARE. 

19 (a) PART A.—Section 1818(a)(3) of the Social Secu20 rity Act (42 U.S.C. 1395i–2(a)(3)) is amended by striking 

21 ‘‘an alien’’ and all that follows through ‘‘under this sec22 tion’’ and inserting ‘‘an individual who is lawfully present 

23 in the United States’’. 

24 (b) PART B.—Section 1836(2) of the Social Security 

25 Act (42 U.S.C. 1395o(2)) is amended by striking ‘‘an 


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1 alien’’ and all that follows through ‘‘under this part’’ and 

2 inserting ‘‘an individual who is lawfully present in the 

3 United States’’. 

4 SEC. 408. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE 

5 PROVIDED BY URBAN INDIAN HEALTH CEN6 TERS. 

7 (a) IN GENERAL.—The third sentence of section 

8 1905(b) of the Social Security Act (42 U.S.C. 1396(b)) 

9 is amended by inserting ‘‘or are received through a pro10 gram operated by an urban Indian organization through 

11 a grant or contract under title V of such Act’’ after ‘‘(as 

12 defined in section 4 of the Indian Health Care Improve13 ment Act)’’. 

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

15 this section shall apply to medical assistance provided on 

16 or after the date of enactment of this Act. 

17 SEC. 409. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE 

18 PROVIDED TO A NATIVE HAWAIIAN THROUGH 

19 A FEDERALLY QUALIFIED HEALTH CENTER 

20 OR A NATIVE HAWAIIAN HEALTH CARE SYS21 TEM UNDER THE MEDICAID PROGRAM. 

22 (a) IN GENERAL.—The third sentence of section 

23 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), 

24 as amended by section 418(a), is amended by inserting 

25 before the period the following: ‘‘; and, with respect to 


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1 medical assistance provided to a Native Hawaiian (as de2 fined in section 12(2) of the Native Hawaiian Health Care 

3 Improvement Act) through a federally qualified health 

4 center or a Native Hawaiian health care system (as de5 fined in section 12(6) of such Act), whether directly, by 

6 referral, or under contract or other arrangement between 

7 such federally qualified health center or Native Hawaiian 

8 health care system and another health care provider’’. 

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

10 this section shall apply to medical assistance provided on 

11 or after the date of enactment of this Act. 

12 Subtitle B—Expansion of Access 

13 SEC. 410. PROTECTING SENSITIVE LOCATIONS. 

14 Section 287 of the Immigration and Nationality Act 

15 (8 U.S.C. 1357) is amended by adding at the end the fol16 lowing: 

17 ‘‘(i)(1) In this subsection: 

18 ‘‘(A) The term ‘appropriate committees of Con19 gress’ means— 

20 ‘‘(i) the Committee on Homeland Security 

21 and Governmental Affairs of the Senate; 

22 ‘‘(ii) the Committee on the Judiciary of the 

23 Senate; 

24 ‘‘(iii) the Committee on Homeland Security 

25 of the House of Representatives; and 


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1 ‘‘(iv) the Committee on the Judiciary of 

2 the House of Representatives. 

3 ‘‘(B) The term ‘enforcement action’— 

4 ‘‘(i) means an apprehension, arrest, inter5 view, request for identification, search, or sur6 veillance for the purposes of immigration en7 forcement; and 

8 ‘‘(ii) includes an enforcement action at, or 

9 focused on, a sensitive location that is part of 

10 a joint case led by another law enforcement 

11 agency. 

12 ‘‘(C) The term ‘exigent circumstances’ means a 

13 situation involving— 

14 ‘‘(i) the imminent risk of death, violence, 

15 or physical harm to any person or property, in16 cluding a situation implicating terrorism or the 

17 national security of the United States; 

18 ‘‘(ii) the immediate arrest or pursuit of a 

19 dangerous felon, terrorist suspect, or other indi20 vidual presenting an imminent danger; or 

21 ‘‘(iii) the imminent risk of destruction of 

22 evidence that is material to an ongoing criminal 

23 case. 

24 ‘‘(D) The term ‘prior approval’ means— 


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1 ‘‘(i) in the case of officers and agents of 

2 U.S. Immigration and Customs Enforcement, 

3 prior written approval to carry out an enforce4 ment action involving a specific individual or in5 dividuals authorized by— 

6 ‘‘(I) the Assistant Director of Oper7 ations, Homeland Security Investigations; 

8 ‘‘(II) the Executive Associate Director 

9 of Homeland Security Investigations; 

10 ‘‘(III) the Assistant Director for Field 

11 Operations, Enforcement and Removal Op12 erations; or 

13 ‘‘(IV) the Executive Associate Direc14 tor for Field Operations, Enforcement and 

15 Removal Operations; 

16 ‘‘(ii) in the case of officers and agents of 

17 U.S. Customs and Border Protection, prior 

18 written approval to carry out an enforcement 

19 action involving a specific individual or individ20 uals authorized by— 

21 ‘‘(I) a Chief Patrol Agent; 

22 ‘‘(II) the Director of Field Operations; 

23 ‘‘(III) the Director of Air and Marine 

24 Operations; or 


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1 ‘‘(IV) the Internal Affairs Special 

2 Agent in Charge; and 

3 ‘‘(iii) in the case of other Federal, State, 

4 or local law enforcement officers, to carry out 

5 an enforcement action involving a specific indi6 vidual or individuals authorized by— 

7 ‘‘(I) the head of the Federal agency 

8 carrying out the enforcement action; or 

9 ‘‘(II) the head of the State or local 

10 law enforcement agency carrying out the 

11 enforcement action. 

12 ‘‘(E) The term ‘sensitive location’ includes all of 

13 the physical space located within 1,000 feet of— 

14 ‘‘(i) any medical treatment or health care 

15 facility, including any hospital, doctor’s office, 

16 accredited health clinic, alcohol or drug treat17 ment center, or emergent or urgent care facil18 ity; 

19 ‘‘(ii) any public or private school, including 

20 any known and licensed day care facility, pre21 school, other early learning program facility, 

22 primary school, secondary school, postsecondary 

23 school (including colleges and universities), or 

24 other institution of learning (including voca25 tional or trade schools); 


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1 ‘‘(iii) any scholastic or education-related 

2 activity or event, including field trips and inter3 scholastic events; 

4 ‘‘(iv) any school bus or school bus stop 

5 during periods when school children are present 

6 on the bus or at the stop; 

7 ‘‘(v) any organization that— 

8 ‘‘(I) assists children, pregnant women, 

9 victims of crime or abuse, or individuals 

10 with significant mental or physical disabil11 ities; or 

12 ‘‘(II) provides disaster or emergency 

13 social services and assistance; 

14 ‘‘(vi) any church, synagogue, mosque, or 

15 other place of worship, including buildings 

16 rented for the purpose of religious services, re17 treats, counseling, workshops, instruction, and 

18 education; 

19 ‘‘(vii) any Federal, State, or local court20 house, including the office of an individual’s 

21 legal counsel or representative, and a probation, 

22 parole, or supervised release office; 

23 ‘‘(viii) the site of a funeral, wedding, or 

24 other religious ceremony or observance; 


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1 ‘‘(ix) any public demonstration, such as a 

2 march, rally, or parade; 

3 ‘‘(x) any domestic violence shelter, rape 

4 crisis center, supervised visitation center, family 

5 justice center, or victim services provider; or 

6 ‘‘(xi) any other location specified by the 

7 Secretary of Homeland Security for purposes of 

8 this subsection. 

9 ‘‘(2)(A) An enforcement action may not take place 

10 at, or be focused on, a sensitive location unless— 

11 ‘‘(i) the action involves exigent circumstances; 

12 and 

13 ‘‘(ii) prior approval for the enforcement action 

14 was obtained from the appropriate official. 

15 ‘‘(B) If an enforcement action is initiated pursuant 

16 to subparagraph (A) and the exigent circumstances per17 mitting the enforcement action cease, the enforcement ac18 tion shall be discontinued until such exigent circumstances 

19 reemerge. 

20 ‘‘(C) If an enforcement action is carried out in viola21 tion of this subsection— 

22 ‘‘(i) no information resulting from the enforce23 ment action may be entered into the record or re24 ceived into evidence in a removal proceeding result25 ing from the enforcement action; and 


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1 ‘‘(ii) the alien who is the subject of such re2 moval proceeding may file a motion for the imme3 diate termination of the removal proceeding. 

4 ‘‘(3)(A) This subsection shall apply to any enforce5 ment action by officers or agents of the Department of 

6 Homeland Security, including— 

7 ‘‘(i) officers or agents of U.S. Immigration and 

8 Customs Enforcement; 

9 ‘‘(ii) officers or agents of U.S. Customs and 

10 Border Protection; and 

11 ‘‘(iii) any individual designated to perform im12 migration enforcement functions pursuant to sub13 section (g). 

14 ‘‘(B) While carrying out an enforcement action at a 

15 sensitive location, officers and agents referred to in sub16 paragraph (A) shall make every effort— 

17 ‘‘(i) to limit the time spent at the sensitive loca18 tion; 

19 ‘‘(ii) to limit the enforcement action at the sen20 sitive location to the person or persons for whom 

21 prior approval was obtained; and 

22 ‘‘(iii) to conduct themselves discreetly. 

23 ‘‘(C) If, while carrying out an enforcement action 

24 that is not initiated at or focused on a sensitive location, 

25 officers or agents are led to a sensitive location, and no 


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1 exigent circumstance and prior approval with respect to 

2 the sensitive location exists, such officers or agents shall— 

3 ‘‘(i) cease before taking any further enforce4 ment action; 

5 ‘‘(ii) conduct themselves in a discreet manner; 

6 ‘‘(iii) maintain surveillance; and 

7 ‘‘(iv) immediately consult their supervisor in 

8 order to determine whether such enforcement action 

9 should be discontinued. 

10 ‘‘(D) The limitations under this paragraph shall not 

11 apply to the transportation of an individual apprehended 

12 at or near a land or sea border to a hospital or health 

13 care provider for the purpose of providing medical care 

14 to such individual. 

15 ‘‘(4)(A) Each official specified in subparagraph (B) 

16 shall ensure that the employees under his or her super17 vision receive annual training on compliance with— 

18 ‘‘(i) the requirements under this subsection in 

19 enforcement actions at or focused on sensitive loca20 tions and enforcement actions that lead officers or 

21 agents to a sensitive location; and 

22 ‘‘(ii) the requirements under section 239 of this 

23 Act and section 384 of the Illegal Immigration Re24 form and Immigrant Responsibility Act of 1996 (8 

25 U.S.C. 1367). 


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1 ‘‘(B) The officials specified in this subparagraph 

2 are— 

3 ‘‘(i) the Chief Counsel of U.S. Immigration and 

4 Customs Enforcement; 

5 ‘‘(ii) the Field Office Directors of U.S. Immi6 gration and Customs Enforcement; 

7 ‘‘(iii) each Special Agent in Charge of U.S. Im8 migration and Customs Enforcement; 

9 ‘‘(iv) each Chief Patrol Agent of U.S. Customs 

10 and Border Protection; 

11 ‘‘(v) the Director of Field Operations of U.S. 

12 Customs and Border Protection; 

13 ‘‘(vi) the Director of Air and Marine Operations 

14 of U.S. Customs and Border Protection; 

15 ‘‘(vii) the Internal Affairs Special Agent in 

16 Charge of U.S. Customs and Border Protection; and 

17 ‘‘(viii) the chief law enforcement officer of each 

18 State or local law enforcement agency that enters 

19 into a written agreement with the Department of 

20 Homeland Security pursuant to subsection (g). 

21 ‘‘(5) The Secretary of Homeland Security shall mod22 ify the Notice to Appear form (I–862)— 

23 ‘‘(A) to provide the subjects of an enforcement 

24 action with information, written in plain language, 

25 summarizing the restrictions against enforcement 


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1 actions at sensitive locations set forth in this sub2 section and the remedies available to the alien if 

3 such action violates such restrictions; 

4 ‘‘(B) so that the information described in sub5 paragraph (A) is accessible to individuals with lim6 ited-English proficiency; and 

7 ‘‘(C) so that subjects of an enforcement action 

8 are not permitted to verify that the officers or 

9 agents that carried out such action complied with 

10 the restrictions set forth in this subsection. 

11 ‘‘(6)(A) The Director of U.S. Immigration and Cus12 toms Enforcement and the Commissioner of U.S. Customs 

13 and Border Protection shall each submit an annual report 

14 to the appropriate committees of Congress that includes 

15 the information set forth in subparagraph (B) with respect 

16 to the respective agency. 

17 ‘‘(B) Each report submitted under subparagraph (A) 

18 shall include, with respect to the submitting agency during 

19 the reporting period— 

20 ‘‘(i) the number of enforcement actions that 

21 were carried out at, or focused on, a sensitive loca22 tion; 

23 ‘‘(ii) the number of enforcement actions in 

24 which officers or agents were subsequently led to a 

25 sensitive location; and 


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1 ‘‘(iii) for each enforcement action described in 

2 clause (i) or (ii)— 

3 ‘‘(I) the date on which it occurred; 

4 ‘‘(II) the specific site, city, county, and 

5 State in which it occurred; 

6 ‘‘(III) the components of the agency in7 volved in the enforcement action; 

8 ‘‘(IV) a description of the enforcement ac9 tion, including the nature of the criminal activ10 ity of its intended target; 

11 ‘‘(V) the number of individuals, if any, ar12 rested or taken into custody; 

13 ‘‘(VI) the number of collateral arrests, if 

14 any, and the reasons for each such arrest; 

15 ‘‘(VII) a certification whether the location 

16 administrator was contacted before, during, or 

17 after the enforcement action; and 

18 ‘‘(VIII) the percentage of all of the staff 

19 members and supervisors reporting to the offi20 cials listed in paragraph (4)(B) who completed 

21 the training required under paragraph (4)(A). 

22 ‘‘(7) Nothing in the subsection may be construed— 

23 ‘‘(A) to affect the authority of Federal, State, 

24 or local law enforcement agencies— 


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1 ‘‘(i) to enforce generally applicable Federal 

2 or State criminal laws unrelated to immigra3 tion; or 

4 ‘‘(ii) to protect residents from imminent 

5 threats to public safety; or 

6 ‘‘(B) to limit or override the protections pro7 vided in— 

8 ‘‘(i) section 239; or 

9 ‘‘(ii) section 384 of the Illegal Immigration 

10 Reform and Immigrant Responsibility Act of 

11 1996 (8 U.S.C. 1367).’’. 

12 SEC. 411. GRANTS FOR RACIAL AND ETHNIC APPROACHES 

13 TO COMMUNITY HEALTH. 

14 (a) PURPOSE.—It is the purpose of this section to 

15 provide for the awarding of grants to assist communities 

16 in mobilizing and organizing resources in support of effec17 tive and sustainable programs that will reduce or eliminate 

18 disparities in health and health care experienced by racial 

19 and ethnic minority individuals. 

20 (b) AUTHORITY TO AWARD GRANTS.—The Secretary 

21 of Health and Human Services, acting through the Ad22 ministrator of the Health Resources and Services Admin23 istration, shall award grants to eligible entities to assist 

24 in designing, implementing, and evaluating culturally and 

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1 driven sustainable strategies to eliminate racial and ethnic 

2 health and health care disparities. 

3 (c) ELIGIBLE ENTITIES.—To be eligible to receive a 

4 grant under this section, an entity shall— 

5 (1) represent a coalition— 

6 (A) whose principal purpose is to develop 

7 and implement interventions to reduce or elimi8 nate a health or health care disparity in a tar9 geted racial or ethnic minority group in the 

10 community served by the coalition; and 

11 (B) that includes— 

12 (i) members selected from among— 

13 (I) public health departments; 

14 (II) community-based organiza15 tions; 

16 (III) university and research or17 ganizations; 

18 (IV) American Indian Tribal or19 ganizations, national American Indian 

20 organizations, Indian Health Service, 

21 or organizations serving Alaska Na22 tives; and 

23 (V) interested public or private 

24 health care providers or organizations 


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1 as deemed appropriate by the Sec2 retary; and 

3 (ii) at least 1 member from a commu4 nity-based organization that represents the 

5 targeted racial or ethnic minority group; 

6 and 

7 (2) submit to the Secretary an application at 

8 such time, in such manner, and containing such in9 formation as the Secretary may require, which shall 

10 include— 

11 (A) a description of the targeted racial or 

12 ethnic populations in the community to be 

13 served under the grant; 

14 (B) a description of at least 1 health dis15 parity that exists in the racial or ethnic tar16 geted populations, including health issues such 

17 as infant mortality, breast and cervical cancer 

18 screening and management, musculoskeletal 

19 diseases and obesity, prostate cancer screening 

20 and management, cardiovascular disease, diabe21 tes, child and adult immunization levels, oral 

22 disease, or other health priority areas as des23 ignated by the Secretary; and 

24 (C) a demonstration of a proven record of 

25 accomplishment of the coalition members in 


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1 serving and working with the targeted commu2 nity. 

3 (d) SUSTAINABILITY.—The Secretary shall give pri4 ority to an eligible entity under this section if the entity 

5 agrees that, with respect to the costs to be incurred by 

6 the entity in carrying out the activities for which the grant 

7 was awarded, the entity (and each of the participating 

8 partners in the coalition represented by the entity) will 

9 maintain its expenditures of non-Federal funds for such 

10 activities at a level that is not less than the level of such 

11 expenditures during the fiscal year immediately preceding 

12 the first fiscal year for which the grant is awarded. 

13 (e) NONDUPLICATION.—Funds provided through this 

14 grant program should supplement, not supplant, existing 

15 Federal funding, and the funds should not be used to du16 plicate the activities of the other health disparity grant 

17 programs in this Act. 

18 (f) TECHNICAL ASSISTANCE.—The Secretary may, 

19 either directly or by grant or contract, provide any entity 

20 that receives a grant under this section with technical and 

21 other nonfinancial assistance necessary to meet the re22 quirements of this section. 

23 (g) DISSEMINATION.—The Secretary shall encourage 

24 and enable grantees to share best practices, evaluation re25 sults, and reports with communities not affiliated with 


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1 grantees using the Internet, conferences, and other perti2 nent information regarding the projects funded by this 

3 section, including the outreach efforts of the Office of Mi4 nority Health and Health Disparity Elimination and the 

5 Centers for Disease Control and Prevention. 

6 (h) ADMINISTRATIVE BURDENS.—The Secretary 

7 shall make every effort to minimize duplicative or unneces8 sary administrative burdens on grantees. 

9 (i) DEFINITION.—In this section, the term ‘‘Sec10 retary’’ means the Secretary of Health and Human Serv11 ices. 

12 (j) AUTHORIZATION OF APPROPRIATIONS.—There 

13 are authorized to be appropriated such sums as may be 

14 necessary to carry out this section. 

15 SEC. 412. CRITICAL ACCESS HOSPITAL IMPROVEMENTS. 

16 (a) ELIMINATION OF ISOLATION TEST FOR COST17 BASED AMBULANCE REIMBURSEMENT.— 

18 (1) IN GENERAL.—Section 1834(l)(8) of the 

19 Social Security Act (42 U.S.C. 1395m(l)(8)) is 

20 amended— 

21 (A) in subparagraph (B)— 

22 (i) by striking ‘‘owned and’’; and 

23 (ii) by inserting ‘‘(including when 

24 such services are provided by the entity 


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1 under an arrangement with the hospital)’’ 

2 after ‘‘hospital’’; and 

3 (B) by striking the comma at the end of 

4 subparagraph (B) and all that follows and in5 serting a period. 

6 (2) EFFECTIVE DATE.—The amendments made 

7 by this subsection shall apply to services furnished 

8 on or after January 1, 2015. 

9 (b) PROVISION OF A MORE FLEXIBLE ALTERNATIVE

10 TO THE CAH DESIGNATION 25 INPATIENT BED LIMIT

11 REQUIREMENT.— 

12 (1) IN GENERAL.—Section 1820(c)(2) of the 

13 Social Security Act (42 U.S.C. 1395i–4(c)(2)) is 

14 amended— 

15 (A) in subparagraph (B)(iii), by striking 

16 ‘‘provides not more than’’ and inserting ‘‘sub17 ject to subparagraph (F), provides not more 

18 than’’; and 

19 (B) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(F) ALTERNATIVE TO 25 INPATIENT BED

22 LIMIT REQUIREMENT.— 

23 ‘‘(i) IN GENERAL.—A State may elect 

24 to treat a facility, with respect to the des25 ignation of the facility for a cost-reporting 


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1 period, as satisfying the requirement of 

2 subparagraph (B)(iii) relating to a max3 imum number of acute care inpatient beds 

4 if the facility elects, in accordance with a 

5 method specified by the Secretary and be6 fore the beginning of the cost reporting pe7 riod, to meet the requirement under clause 

8 (ii). 

9 ‘‘(ii) ALTERNATE REQUIREMENT.— 

10 The requirement under this clause, with 

11 respect to a facility and a cost-reporting 

12 period, is that the total number of inpa13 tient bed days described in subparagraph 

14 (B)(iii) during such period will not exceed 

15 7,300. For purposes of this subparagraph, 

16 an individual who is an inpatient in a bed 

17 in the facility for a single day shall be 

18 counted as one inpatient bed day. 

19 ‘‘(iii) WITHDRAWAL OF ELECTION.— 

20 The option described in clause (i) shall not 

21 apply to a facility for a cost-reporting pe22 riod if the facility (for any two consecutive 

23 cost-reporting periods during the previous 

24 5 cost-reporting periods) was treated under 

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1 patient bed days for each of such two cost2 reporting periods that exceeded the num3 ber specified in such clause.’’. 

4 (2) EFFECTIVE DATE.—The amendments made 

5 by paragraph (1) shall apply to cost-reporting peri6 ods beginning on or after the date of the enactment 

7 of this Act. 

8 SEC. 413. ESTABLISHMENT OF RURAL COMMUNITY HOS9 PITAL (RCH) PROGRAM. 

10 (a) IN GENERAL.—Section 1861 of the Social Secu11 rity Act (42 U.S.C. 1395x), as amended by section 

12 205(b)(1), is amended by adding at the end of the fol13 lowing new subsection: 

14 ‘‘Rural Community Hospital; Rural Community Hospital 

15 Services 

16 ‘‘(jjj)(1) The term ‘rural community hospital’ means 

17 a hospital (as defined in subsection (e)) that— 

18 ‘‘(A) is located in a rural area (as defined in 

19 section 1886(d)(2)(D)) or treated as being so lo20 cated pursuant to section 1886(d)(8)(E); 

21 ‘‘(B) subject to paragraph (2), has less than 51 

22 acute care inpatient beds, as reported in its most re23 cent cost report; 

24 ‘‘(C) makes available 24-hour emergency care 

25 services; 


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1 ‘‘(D) subject to paragraph (3), has a provider 

2 agreement in effect with the Secretary and is open 

3 to the public as of January 1, 2010; and 

4 ‘‘(E) applies to the Secretary for such designa5 tion. 

6 ‘‘(2) For purposes of paragraph (1)(B), beds in a 

7 psychiatric or rehabilitation unit of the hospital which is 

8 a distinct part of the hospital shall not be counted. 

9 ‘‘(3) Paragraph (1)(D) shall not be construed to pro10 hibit any of the following from qualifying as a rural com11 munity hospital: 

12 ‘‘(A) A replacement facility (as defined by the 

13 Secretary in regulations in effect on January 1, 

14 2012) with the same service area (as defined by the 

15 Secretary in regulations in effect on such date). 

16 ‘‘(B) A facility obtaining a new provider num17 ber pursuant to a change of ownership. 

18 ‘‘(C) A facility which has a binding written 

19 agreement with an outside, unrelated party for the 

20 construction, reconstruction, lease, rental, or financ21 ing of a building as of January 1, 2012. 

22 ‘‘(4) Nothing in this subsection shall be construed as 

23 prohibiting a critical access hospital from qualifying as a 

24 rural community hospital if the critical access hospital 


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1 meets the conditions otherwise applicable to hospitals 

2 under subsection (e) and section 1866. 

3 ‘‘(5) Nothing in this subsection shall be construed as 

4 prohibiting a rural community hospital participating in 

5 the demonstration program under section 410A of the 

6 Medicare Prescription Drug, Improvement, and Mod7 ernization Act of 2003 (Public Law 108–173; 117 Stat. 

8 2313) from qualifying as a rural community hospital if 

9 the rural community hospital meets the conditions other10 wise applicable to hospitals under subsection (e) and sec11 tion 1866.’’. 

12 (b) PAYMENT.— 

13 (1) INPATIENT HOSPITAL SERVICES.—Section 

14 1814 of the Social Security Act (42 U.S.C. 1395f) 

15 is amended by adding at the end the following new 

16 subsection: 

17 ‘‘Payment for Inpatient Services Furnished in Rural 

18 Community Hospitals 

19 ‘‘(m) The amount of payment under this part for in20 patient hospital services furnished in a rural community 

21 hospital, other than such services furnished in a psy22 chiatric or rehabilitation unit of the hospital which is a 

23 distinct part, is, at the election of the hospital in the appli24 cation referred to in section 1861(jjj)(1)(E)— 


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1 ‘‘(1) 101 percent of the reasonable costs of pro2 viding such services, without regard to the amount 

3 of the customary or other charge, or 

4 ‘‘(2) the amount of payment provided for under 

5 the prospective payment system for inpatient hos6 pital services under section 1886(d).’’. 

7 (2) OUTPATIENT SERVICES.—Section 1834 of 

8 such Act (42 U.S.C. 1395m) is amended by adding 

9 at the end the following new subsection: 

10 ‘‘(p) PAYMENT FOR OUTPATIENT SERVICES FUR11 NISHED IN RURAL COMMUNITY HOSPITALS.—The 

12 amount of payment under this part for outpatient services 

13 furnished in a rural community hospital is, at the election 

14 of the hospital in the application referred to in section 

15 1861(jjj)(1)(E)— 

16 ‘‘(1) 101 percent of the reasonable costs of pro17 viding such services, without regard to the amount 

18 of the customary or other charge and any limitation 

19 under section 1861(v)(1)(U), or 

20 ‘‘(2) the amount of payment provided for under 

21 the prospective payment system for covered OPD 

22 services under section 1833(t).’’. 

23 (3) EXEMPTION FROM 30-PERCENT REDUCTION

24 IN REIMBURSEMENT FOR BAD DEBT.—Section 

25 1861(v)(1)(T) of such Act (42 U.S.C. 


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1 1395x(v)(1)(T)) is amended by inserting ‘‘(other 

2 than for a rural community hospital)’’ after ‘‘In de3 termining such reasonable costs for hospitals’’. 

4 (c) BENEFICIARY COST-SHARING FOR OUTPATIENT

5 SERVICES.—Section 1834(p) of such Act (as added by 

6 subsection (b)(2)) is amended— 

7 (1) by redesignating paragraphs (1) and (2) as 

8 subparagraphs (A) and (B), respectively; 

9 (2) by inserting ‘‘(1)’’ after ‘‘(p)’’; and 

10 (3) by adding at the end the following: 

11 ‘‘(2) The amounts of beneficiary cost-sharing for out12 patient services furnished in a rural community hospital 

13 under this part shall be as follows: 

14 ‘‘(A) For items and services that would have 

15 been paid under section 1833(t) if provided by a 

16 hospital, the amount of cost-sharing determined 

17 under paragraph (8) of such section. 

18 ‘‘(B) For items and services that would have 

19 been paid under section 1833(h) if furnished by a 

20 provider or supplier, no cost-sharing shall apply. 

21 ‘‘(C) For all other items and services, the 

22 amount of cost-sharing that would apply to the item 

23 or service under the methodology that would be used 

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1 vided by a physician, provider, or supplier, as the 

2 case may be.’’. 

3 (d) CONFORMING AMENDMENTS.— 

4 (1) PART A PAYMENT.—Section 1814(b) of 

5 such Act (42 U.S.C. 1395f(b)) is amended in the 

6 matter preceding paragraph (1) by inserting ‘‘other 

7 than inpatient hospital services furnished by a rural 

8 community hospital,’’ after ‘‘critical access hospital 

9 services,’’. 

10 (2) PART B PAYMENT.—Section 1833(a) of 

11 such Act (42 U.S.C. 1395l(a)), as amended by sec12 tion 205(b)(3), is amended— 

13 (A) in paragraph (2), in the matter before 

14 subparagraph (A), by striking ‘‘and (I)’’ and in15 serting ‘‘(I), and (K)’’; 

16 (B) by striking ‘‘and’’ at the end of para17 graph (9); 

18 (C) by striking the period at the end of 

19 paragraph (10) and inserting ‘‘; and’’; and 

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

21 ‘‘(11) in the case of outpatient services fur22 nished by a rural community hospital, the amounts 

23 described in section 1834(p).’’. 

24 (3) TECHNICAL AMENDMENTS.— 


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1 (A) CONSULTATION WITH STATE AGEN2 CIES.—Section 1863 of such Act (42 U.S.C. 

3 1395z) is amended by striking ‘‘and (dd)(2)’’ 

4 and inserting ‘‘(dd)(2), (mm)(1), and (jjj)(1)’’. 

5 (B) PROVIDER AGREEMENTS.—Section 

6 1866(a)(2)(A) of such Act (42 U.S.C. 

7 1395cc(a)(2)(A)) is amended by inserting ‘‘sec8 tion 1834(p)(2),’’ after ‘‘section 1833(b),’’. 

9 (e) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply to items and services furnished on 

11 or after October 1, 2016. 

12 SEC. 414. MEDICARE REMOTE MONITORING PILOT 

13 PROJECTS. 

14 (a) PILOT PROJECTS.— 

15 (1) IN GENERAL.—Not later than 9 months 

16 after the date of enactment of this Act, the Sec17 retary of Health and Human Services (in this sec18 tion referred to as the ‘‘Secretary’’) shall conduct 

19 pilot projects under title XVIII of the Social Secu20 rity Act for the purpose of providing incentives to 

21 home health agencies to utilize home monitoring and 

22 communications technologies that— 

23 (A) enhance health outcomes for Medicare 

24 beneficiaries; and 

25 (B) reduce expenditures under such title. 


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1 (2) SITE REQUIREMENTS.— 

2 (A) URBAN AND RURAL.—The Secretary 

3 shall conduct the pilot projects under this sec4 tion in both urban and rural areas. 

5 (B) SITE IN A SMALL STATE.—The Sec6 retary shall conduct at least 3 of the pilot 

7 projects in a State with a population of less 

8 than 1,000,000. 

9 (3) DEFINITION OF HOME HEALTH AGENCY.— 

10 In this section, the term ‘‘home health agency’’ has 

11 the meaning given that term in section 1861(o) of 

12 the Social Security Act (42 U.S.C. 1395x(o)). 

13 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

14 OF PROJECTS.—The Secretary shall specify the criteria 

15 for identifying those Medicare beneficiaries who shall be 

16 considered within the scope of the pilot projects under this 

17 section for purposes of the application of subsection (c) 

18 and for the assessment of the effectiveness of the home 

19 health agency in achieving the objectives of this section. 

20 Such criteria may provide for the inclusion in the projects 

21 of Medicare beneficiaries who begin receiving home health 

22 services under title XVIII of the Social Security Act after 

23 the date of the implementation of the projects. 

24 (c) INCENTIVES.— 


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1 (1) PERFORMANCE TARGETS.—The Secretary 

2 shall establish for each home health agency partici3 pating in a pilot project under this section a per4 formance target using one of the following meth5 odologies, as determined appropriate by the Sec6 retary: 

7 (A) ADJUSTED HISTORICAL PERFORMANCE

8 TARGET.—The Secretary shall establish for the 

9 agency— 

10 (i) a base expenditure amount equal 

11 to the average total payments made to the 

12 agency under parts A and B of title XVIII 

13 of the Social Security Act for Medicare 

14 beneficiaries determined to be within the 

15 scope of the pilot project in a base period 

16 determined by the Secretary; and 

17 (ii) an annual per capita expenditure 

18 target for such beneficiaries, reflecting the 

19 base expenditure amount adjusted for risk 

20 and adjusted growth rates. 

21 (B) COMPARATIVE PERFORMANCE TAR22 GET.—The Secretary shall establish for the 

23 agency a comparative performance target equal 

24 to the average total payments under such parts 

25 A and B during the pilot project for comparable 


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1 individuals in the same geographic area that 

2 are not determined to be within the scope of the 

3 pilot project. 

4 (2) INCENTIVE.—Subject to paragraph (3), the 

5 Secretary shall pay to each participating home care 

6 agency an incentive payment for each year under the 

7 pilot project equal to a portion of the Medicare sav8 ings realized for such year relative to the perform9 ance target under paragraph (1). 

10 (3) LIMITATION ON EXPENDITURES.—The Sec11 retary shall limit incentive payments under this sec12 tion in order to ensure that the aggregate expendi13 tures under title XVIII of the Social Security Act 

14 (including incentive payments under this subsection) 

15 do not exceed the amount that the Secretary esti16 mates would have been expended if the pilot projects 

17 under this section had not been implemented. 

18 (d) WAIVER AUTHORITY.—The Secretary may waive 

19 such provisions of titles XI and XVIII of the Social Secu20 rity Act as the Secretary determines to be appropriate for 

21 the conduct of the pilot projects under this section. 

22 (e) REPORT TO CONGRESS.—Not later than 5 years 

23 after the date that the first pilot project under this section 

24 is implemented, the Secretary shall submit to Congress a 

25 report on the pilot projects. Such report shall contain a 


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1 detailed description of issues related to the expansion of 

2 the projects under subsection (f) and recommendations for 

3 such legislation and administrative actions as the Sec4 retary considers appropriate. 

5 (f) EXPANSION.—If the Secretary determines that 

6 any of the pilot projects under this section enhance health 

7 outcomes for Medicare beneficiaries and reduce expendi8 tures under title XVIII of the Social Security Act, the Sec9 retary may initiate comparable projects in additional 

10 areas. 

11 (g) INCENTIVE PAYMENTS HAVE NO EFFECT ON

12 OTHER MEDICARE PAYMENTS TO AGENCIES.—An incen13 tive payment under this section— 

14 (1) shall be in addition to the payments that a 

15 home health agency would otherwise receive under 

16 title XVIII of the Social Security Act for the provi17 sion of home health services; and 

18 (2) shall have no effect on the amount of such 

19 payments. 

20 SEC. 415. RURAL HEALTH QUALITY ADVISORY COMMISSION 

21 AND DEMONSTRATION PROJECTS. 

22 (a) RURAL HEALTH QUALITY ADVISORY COMMIS23 SION.— 

24 (1) ESTABLISHMENT.—Not later than 6 

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1 tion, the Secretary of Health and Human Services 

2 (in this section referred to as the ‘‘Secretary’’) shall 

3 establish a commission to be known as the Rural 

4 Health Quality Advisory Commission (in this section 

5 referred to as the ‘‘Commission’’). 

6 (2) DUTIES OF COMMISSION.— 

7 (A) NATIONAL PLAN.—The Commission 

8 shall develop, coordinate, and facilitate imple9 mentation of a national plan for rural health 

10 quality improvement. The national plan shall— 

11 (i) identify objectives for rural health 

12 quality improvement; 

13 (ii) identify strategies to eliminate 

14 known gaps in rural health system capacity 

15 and improve rural health quality; and 

16 (iii) provide for Federal programs to 

17 identify opportunities for strengthening 

18 and aligning policies and programs to im19 prove rural health quality. 

20 (B) DEMONSTRATION PROJECTS.—The 

21 Commission shall design demonstration projects 

22 to test alternative models for rural health qual23 ity improvement, including with respect to both 

24 personal and population health. 


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1 (C) MONITORING.—The Commission shall 

2 monitor progress toward the objectives identi3 fied pursuant to paragraph (1)(A). 

4 (3) MEMBERSHIP.— 

5 (A) NUMBER.—The Commission shall be 

6 composed of 11 members appointed by the Sec7 retary. 

8 (B) SELECTION.—The Secretary shall se9 lect the members of the Commission from 

10 among individuals with significant rural health 

11 care and health care quality expertise, including 

12 expertise in clinical health care, health care 

13 quality research, population or public health, or 

14 purchaser organizations. 

15 (4) CONTRACTING AUTHORITY.—Subject to the 

16 availability of funds, the Commission may enter into 

17 contracts and make other arrangements, as may be 

18 necessary to carry out the duties described in para19 graph (2). 

20 (5) STAFF.—Upon the request of the Commis21 sion, the Secretary may detail, on a reimbursable 

22 basis, any of the personnel of the Office of Rural 

23 Health Policy of the Health Resources and Services 

24 Administration, the Agency for Healthcare Quality 

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1 icaid Services to the Commission to assist in car2 rying out this subsection. 

3 (6) REPORTS TO CONGRESS.—Not later than 1 

4 year after the establishment of the Commission, and 

5 annually thereafter, the Commission shall submit a 

6 report to the Congress on rural health quality. Each 

7 such report shall include the following: 

8 (A) An inventory of relevant programs and 

9 recommendations for improved coordination and 

10 integration of policy and programs. 

11 (B) An assessment of achievement of the 

12 objectives identified in the national plan devel13 oped under paragraph (2) and recommenda14 tions for realizing such objectives. 

15 (C) Recommendations on Federal legisla16 tion, regulations, or administrative policies to 

17 enhance rural health quality and outcomes. 

18 (b) RURAL HEALTH QUALITY DEMONSTRATION

19 PROJECTS.— 

20 (1) IN GENERAL.—Not later than 270 days 

21 after the date of the enactment of this section, the 

22 Secretary, in consultation with the Rural Health 

23 Quality Advisory Commission, the Office of Rural 

24 Health Policy of the Health Resources and Services 

25 Administration, the Agency for Healthcare Research 


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1 and Quality, and the Centers for Medicare & Med2 icaid Services, shall make grants to eligible entities 

3 for 5 demonstration projects to implement and 

4 evaluate methods for improving the quality of health 

5 care in rural communities. Each such demonstration 

6 project shall include— 

7 (A) alternative community models that— 

8 (i) will achieve greater integration of 

9 personal and population health services; 

10 and 

11 (ii) address safety, effectiveness, 

12 patient- or community-centeredness, timeli13 ness, efficiency, and equity (the 6 aims 

14 identified by the Institute of Medicine of 

15 the National Academies in its report enti16 tled ‘‘Crossing the Quality Chasm: A New 

17 Health System for the 21st Century’’ re18 leased on March 1, 2001); 

19 (B) innovative approaches to the financing 

20 and delivery of health services to achieve rural 

21 health quality goals; and 

22 (C) development of quality improvement 

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1 ing, clinical care protocols, and information 

2 technology applications). 

3 (2) ELIGIBLE ENTITIES.—In this subsection, 

4 the term ‘‘eligible entity’’ means a consortium 

5 that— 

6 (A) shall include— 

7 (i) at least one health care provider or 

8 health care delivery system located in a 

9 rural area; and 

10 (ii) at least one organization rep11 resenting multiple community stakeholders; 

12 and 

13 (B) may include other partners such as 

14 rural research centers. 

15 (3) CONSULTATION.—In developing the pro16 gram for awarding grants under this subsection, the 

17 Secretary shall consult with the Administrator of the 

18 Agency for Healthcare Research and Quality, rural 

19 health care providers, rural health care researchers, 

20 and private and nonprofit groups (including national 

21 associations) which are undertaking similar efforts. 

22 (4) EXPEDITED WAIVERS.—The Secretary shall 

23 expedite the processing of any waiver that— 


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1 (A) is authorized under title XVIII or XIX 

2 of the Social Security Act (42 U.S.C. 1395 et 

3 seq.); and 

4 (B) is necessary to carry out a demonstra5 tion project under this subsection. 

6 (5) DEMONSTRATION PROJECT SITES.—The 

7 Secretary shall ensure that the 5 demonstration 

8 projects funded under this subsection are conducted 

9 at a variety of sites representing the diversity of 

10 rural communities in the Nation. 

11 (6) DURATION.—Each demonstration project 

12 under this subsection shall be for a period of 4 

13 years. 

14 (7) INDEPENDENT EVALUATION.—The Sec15 retary shall enter into an arrangement with an enti16 ty that has experience working directly with rural 

17 health systems for the conduct of an independent 

18 evaluation of the program carried out under this 

19 subsection. 

20 (8) REPORT.—Not later than 1 year after the 

21 conclusion of all of the demonstration projects fund22 ed under this subsection, the Secretary shall submit 

23 a report to the Congress on the results of such 

24 projects. The report shall include— 


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1 (A) an evaluation of patient access to care, 

2 patient outcomes, and an analysis of the cost 

3 effectiveness of each such project; and 

4 (B) recommendations on Federal legisla5 tion, regulations, or administrative policies to 

6 enhance rural health quality and outcomes. 

7 (c) APPROPRIATION.— 

8 (1) IN GENERAL.—Out of funds in the Treas9 ury not otherwise appropriated, there are appro10 priated to the Secretary to carry out this section 

11 $30,000,000 for the period of fiscal years 2019 

12 through 2023. 

13 (2) AVAILABILITY.— 

14 (A) IN GENERAL.—Funds appropriated 

15 under paragraph (1) shall remain available for 

16 expenditure through fiscal year 2023. 

17 (B) REPORT.—For purposes of carrying 

18 out subsection (b)(8), funds appropriated under 

19 paragraph (1) shall remain available for ex20 penditure through fiscal year 2024. 

21 (3) RESERVATION.—Of the amount appro22 priated under paragraph (1), the Secretary shall re23 serve— 

24 (A) $5,000,000 to carry out subsection (a); 

25 and 


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1 (B) $25,000,000 to carry out subsection 

2 (b), of which— 

3 (i) 2 percent shall be for the provision 

4 of technical assistance to grant recipients; 

5 and 

6 (ii) 5 percent shall be for independent 

7 evaluation under subsection (b)(7). 

8 SEC. 416. RURAL HEALTH CARE SERVICES. 

9 Section 330A of the Public Health Service Act (42 

10 U.S.C. 254c) is amended to read as follows: 

11 ‘‘SEC. 330A. RURAL HEALTH CARE SERVICES OUTREACH, 

12 RURAL HEALTH NETWORK DEVELOPMENT, 

13 DELTA RURAL DISPARITIES AND HEALTH 

14 SYSTEMS DEVELOPMENT, AND SMALL RURAL 

15 HEALTH CARE PROVIDER QUALITY IMPROVE16 MENT GRANT PROGRAMS. 

17 ‘‘(a) PURPOSE.—The purpose of this section is to 

18 provide for grants— 

19 ‘‘(1) under subsection (b), to promote rural 

20 health care services outreach; 

21 ‘‘(2) under subsection (c), to provide for the 

22 planning and implementation of integrated health 

23 care networks in rural areas; 

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1 parities and to promote and enhance health system 

2 development; and 

3 ‘‘(4) under subsection (e), to provide for the 

4 planning and implementation of small rural health 

5 care provider quality improvement activities. 

6 ‘‘(b) RURAL HEALTH CARE SERVICES OUTREACH

7 GRANTS.— 

8 ‘‘(1) GRANTS.—The Director of the Office of 

9 Rural Health Policy of the Health Resources and 

10 Services Administration may award grants to eligible 

11 entities to promote rural health care services out12 reach by expanding the delivery of health care serv13 ices to include new and enhanced services in rural 

14 areas. The Director may award the grants for peri15 ods of not more than 3 years. 

16 ‘‘(2) ELIGIBILITY.—To be eligible to receive a 

17 grant under this subsection for a project, an enti18 ty— 

19 ‘‘(A) shall be a rural public or rural non20 profit private entity, a facility that qualifies as 

21 a rural health clinic under title XVIII of the 

22 Social Security Act, a public or nonprofit entity 

23 existing exclusively to provide services to mi24 grant and seasonal farm workers in rural areas, 

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1 tivities will be conducted within federally recog2 nized Tribal areas; 

3 ‘‘(B) shall represent a consortium com4 posed of members— 

5 ‘‘(i) that include 3 or more independ6 ently owned health care entities; and 

7 ‘‘(ii) that may be nonprofit or for8 profit entities; and 

9 ‘‘(C) shall not previously have received a 

10 grant under this subsection for the same or a 

11 similar project, unless the entity is proposing to 

12 expand the scope of the project or the area that 

13 will be served through the project. 

14 ‘‘(3) APPLICATIONS.—To be eligible to receive a 

15 grant under this subsection, an eligible entity shall 

16 prepare and submit to the Director an application at 

17 such time, in such manner, and containing such in18 formation as the Director may require, including— 

19 ‘‘(A) a description of the project that the 

20 eligible entity will carry out using the funds 

21 provided under the grant; 

22 ‘‘(B) a description of the manner in which 

23 the project funded under the grant will meet 

24 the health care needs of rural populations in 

25 the local community or region to be served; 


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1 ‘‘(C) a plan for quantifying how health 

2 care needs will be met through identification of 

3 the target population and benchmarks of service 

4 delivery or health status, such as— 

5 ‘‘(i) quantifiable measurements of 

6 health status improvement for projects fo7 cusing on health promotion; or 

8 ‘‘(ii) benchmarks of increased access 

9 to primary care, including tracking factors 

10 such as the number and type of primary 

11 care visits, identification of a medical 

12 home, or other general measures of such 

13 access; 

14 ‘‘(D) a description of how the local com15 munity or region to be served will be involved 

16 in the development and ongoing operations of 

17 the project; 

18 ‘‘(E) a plan for sustaining the project after 

19 Federal support for the project has ended; 

20 ‘‘(F) a description of how the project will 

21 be evaluated; 

22 ‘‘(G) the administrative capacity to submit 

23 annual performance data electronically as speci24 fied by the Director; and 


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1 ‘‘(H) other such information as the Direc2 tor determines to be appropriate. 

3 ‘‘(c) RURAL HEALTH NETWORK DEVELOPMENT

4 GRANTS.— 

5 ‘‘(1) GRANTS.— 

6 ‘‘(A) IN GENERAL.—The Director may 

7 award rural health network development grants 

8 to eligible entities to promote, through planning 

9 and implementation, the development of inte10 grated health care networks that have combined 

11 the functions of the entities participating in the 

12 networks in order to— 

13 ‘‘(i) achieve efficiencies and economies 

14 of scale; 

15 ‘‘(ii) expand access to, coordinate, and 

16 improve the quality of the health care de17 livery system through development of orga18 nizational efficiencies; 

19 ‘‘(iii) implement health information 

20 technology to achieve efficiencies, reduce 

21 medical errors, and improve quality; 

22 ‘‘(iv) coordinate care and manage 

23 chronic illness; and 

24 ‘‘(v) strengthen the rural health care 

25 system as a whole in such a manner as to 


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1 show a quantifiable return on investment 

2 to the participants in the network. 

3 ‘‘(B) GRANT PERIODS.—The Director may 

4 award such a rural health network development 

5 grant— 

6 ‘‘(i) for a period of 3 years for imple7 mentation activities; or 

8 ‘‘(ii) for a period of 1 year for plan9 ning activities to assist in the initial devel10 opment of an integrated health care net11 work, if the proposed participants in the 

12 network do not have a history of collabo13 rative efforts and a 3-year grant would be 

14 inappropriate. 

15 ‘‘(2) ELIGIBILITY.—To be eligible to receive a 

16 grant under this subsection, an entity— 

17 ‘‘(A) shall be a rural public or rural non18 profit private entity, a facility that qualifies as 

19 a rural health clinic under title XVIII of the 

20 Social Security Act, a public or nonprofit entity 

21 existing exclusively to provide services to mi22 grant and seasonal farm workers in rural areas, 

23 or a Tribal government whose grant-funded ac24 tivities will be conducted within federally recog25 nized Tribal areas; 


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1 ‘‘(B) shall represent a network composed 

2 of participants— 

3 ‘‘(i) that include 3 or more independ4 ently owned health care entities; and 

5 ‘‘(ii) that may be nonprofit or for6 profit entities; and 

7 ‘‘(C) shall not previously have received a 

8 grant under this subsection (other than a 1- 

9 year grant for planning activities) for the same 

10 or a similar project. 

11 ‘‘(3) APPLICATIONS.—To be eligible to receive a 

12 grant under this subsection, an eligible entity, in 

13 consultation with the appropriate State office of 

14 rural health or another appropriate State entity, 

15 shall prepare and submit to the Director an applica16 tion at such time, in such manner, and containing 

17 such information as the Director may require, in18 cluding— 

19 ‘‘(A) a description of the project that the 

20 eligible entity will carry out using the funds 

21 provided under the grant; 

22 ‘‘(B) an explanation of the reasons why 

23 Federal assistance is required to carry out the 

24 project; 

25 ‘‘(C) a description of— 


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1 ‘‘(i) the history of collaborative activi2 ties carried out by the participants in the 

3 network; 

4 ‘‘(ii) the degree to which the partici5 pants are ready to integrate their func6 tions; and 

7 ‘‘(iii) how the local community or re8 gion to be served will benefit from and be 

9 involved in the activities carried out by the 

10 network; 

11 ‘‘(D) a description of how the local com12 munity or region to be served will experience in13 creased access to quality health care services 

14 across the continuum of care as a result of the 

15 integration activities carried out by the net16 work, including a description of— 

17 ‘‘(i) return on investment for the com18 munity and the network members; and 

19 ‘‘(ii) other quantifiable performance 

20 measures that show the benefit of the net21 work activities; 

22 ‘‘(E) a plan for sustaining the project after 

23 Federal support for the project has ended; 

24 ‘‘(F) a description of how the project will 

25 be evaluated; 


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1 ‘‘(G) the administrative capacity to submit 

2 annual performance data electronically as speci3 fied by the Director; and 

4 ‘‘(H) other such information as the Direc5 tor determines to be appropriate. 

6 ‘‘(d) DELTA RURAL DISPARITIES AND HEALTH SYS7 TEMS DEVELOPMENT GRANTS.— 

8 ‘‘(1) GRANTS.—The Director may award grants 

9 to eligible entities to support reduction of health dis10 parities, improve access to health care, and enhance 

11 rural health system development in the Delta Re12 gion. 

13 ‘‘(2) ELIGIBILITY.—To be eligible to receive a 

14 grant under this subsection, an entity shall be a 

15 rural public or rural nonprofit private entity, a facil16 ity that qualifies as a rural health clinic under title 

17 XVIII of the Social Security Act, a public or non18 profit entity existing exclusively to provide services 

19 to migrant and seasonal farm workers in rural 

20 areas, or a Tribal government whose grant-funded 

21 activities will be conducted within federally recog22 nized Tribal areas. 

23 ‘‘(3) APPLICATIONS.—To be eligible to receive a 

24 grant under this subsection, an eligible entity shall 

25 prepare and submit to the Director an application at 


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1 such time, in such manner, and containing such in2 formation as the Director may require, including— 

3 ‘‘(A) a description of the project that the 

4 eligible entity will carry out using the funds 

5 provided under the grant; 

6 ‘‘(B) an explanation of the reasons why 

7 Federal assistance is required to carry out the 

8 project; 

9 ‘‘(C) a description of the manner in which 

10 the project funded under the grant will meet 

11 the health care needs of the Delta Region; 

12 ‘‘(D) a description of how the local com13 munity or region to be served will experience in14 creased access to quality health care services as 

15 a result of the activities carried out by the enti16 ty; 

17 ‘‘(E) a description of how health dispari18 ties will be reduced or the health system will be 

19 improved; 

20 ‘‘(F) a plan for sustaining the project after 

21 Federal support for the project has ended; 

22 ‘‘(G) a description of how the project will 

23 be evaluated including process and outcome 

24 measures related to the quality of care provided 


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1 or how the health care system improves its per2 formance; 

3 ‘‘(H) a description of how the grantee will 

4 develop an advisory group made up of rep5 resentatives of the communities to be served to 

6 provide guidance to the grantee to best meet 

7 community need; and 

8 ‘‘(I) other such information as the Director 

9 determines to be appropriate. 

10 ‘‘(e) SMALL RURAL HEALTH CARE PROVIDER QUAL11 ITY IMPROVEMENT GRANTS.— 

12 ‘‘(1) GRANTS.—The Director may award grants 

13 to provide for the planning and implementation of 

14 small rural health care provider quality improvement 

15 activities. The Director may award the grants for 

16 periods of 1 to 3 years. 

17 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

18 under this subsection, an entity— 

19 ‘‘(A) shall be— 

20 ‘‘(i) a rural public or rural nonprofit 

21 private health care provider or provider of 

22 health care services, such as a rural health 

23 clinic; or 

24 ‘‘(ii) another rural provider or net25 work of small rural providers identified by 


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1 the Director as a key source of local care; 

2 and 

3 ‘‘(B) shall not previously have received a 

4 grant under this subsection for the same or a 

5 similar project. 

6 ‘‘(3) PREFERENCE.—In awarding grants under 

7 this subsection, the Director shall give preference to 

8 facilities that qualify as rural health clinics under 

9 title XVIII of the Social Security Act. 

10 ‘‘(4) APPLICATIONS.—To be eligible to receive a 

11 grant under this subsection, an eligible entity shall 

12 prepare and submit to the Director an application at 

13 such time, in such manner, and containing such in14 formation as the Director may require, including— 

15 ‘‘(A) a description of the project that the 

16 eligible entity will carry out using the funds 

17 provided under the grant; 

18 ‘‘(B) an explanation of the reasons why 

19 Federal assistance is required to carry out the 

20 project; 

21 ‘‘(C) a description of the manner in which 

22 the project funded under the grant will assure 

23 continuous quality improvement in the provision 

24 of services by the entity; 


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1 ‘‘(D) a description of how the local com2 munity or region to be served will experience in3 creased access to quality health care services as 

4 a result of the activities carried out by the enti5 ty; 

6 ‘‘(E) a plan for sustaining the project after 

7 Federal support for the project has ended; 

8 ‘‘(F) a description of how the project will 

9 be evaluated including process and outcome 

10 measures related to the quality of care pro11 vided; and 

12 ‘‘(G) other such information as the Direc13 tor determines to be appropriate. 

14 ‘‘(f) GENERAL REQUIREMENTS.— 

15 ‘‘(1) PROHIBITED USES OF FUNDS.—An entity 

16 that receives a grant under this section may not use 

17 funds provided through the grant— 

18 ‘‘(A) to build or acquire real property; or 

19 ‘‘(B) for construction. 

20 ‘‘(2) COORDINATION WITH OTHER AGENCIES.— 

21 The Director shall coordinate activities carried out 

22 under grant programs described in this section, to 

23 the extent practicable, with Federal and State agen24 cies and nonprofit organizations that are operating 


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1 similar grant programs, to maximize the effect of 

2 public dollars in funding meritorious proposals. 

3 ‘‘(g) REPORT.—Not later than September 30, 2020, 

4 the Secretary shall prepare and submit to the appropriate 

5 committees of Congress a report on the progress and ac6 complishments of the grant programs described in sub7 sections (b), (c), (d), and (e). 

8 ‘‘(h) DEFINITIONS.—In this section: 

9 ‘‘(1) The term ‘Delta Region’ has the meaning 

10 given to the term ‘region’ in section 382A of the 

11 Consolidated Farm and Rural Development Act (7 

12 U.S.C. 2009aa). 

13 ‘‘(2) The term ‘Director’ means the Director of 

14 the Office of Rural Health Policy of the Health Re15 sources and Services Administration. 

16 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There 

17 are authorized to be appropriated to carry out this section 

18 $40,000,000 for fiscal year 2019, and such sums as may 

19 be necessary for each of fiscal years 2020 through 2023.’’. 

20 SEC. 417. COMMUNITY HEALTH CENTER COLLABORATIVE 

21 ACCESS EXPANSION. 

22 Section 330 of the Public Health Service Act (42 

23 U.S.C. 254b) is amended by adding at the end the fol24 lowing: 

25 ‘‘(s) MISCELLANEOUS PROVISIONS.— 


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1 ‘‘(1) RULE OF CONSTRUCTION WITH RESPECT

2 TO RURAL HEALTH CLINICS.—Nothing in this sec3 tion shall be construed to prevent a community 

4 health center from contracting with a federally cer5 tified rural health clinic (as defined by section 

6 1861(aa)(2) of the Social Security Act) for the deliv7 ery of primary health care and other mental, dental, 

8 and physical health services that are available at the 

9 rural health clinic to individuals who would other10 wise be eligible for free or reduced cost care if that 

11 individual were able to obtain that care at the com12 munity health center. Such services may be limited 

13 in scope to those primary health care and other 

14 mental, dental, and physical health services available 

15 in that rural health clinic. 

16 ‘‘(2) ENABLING SERVICES.—To the extent pos17 sible, enabling services such as transportation and 

18 language assistance (including translation and inter19 pretation) shall be provided by rural health clinics 

20 described in paragraph (1). 

21 ‘‘(3) ASSURANCES.—In order for a rural health 

22 clinic to receive funds under this section through a 

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1 scribed in paragraph (1), such rural health clinic 

2 shall establish policies to ensure— 

3 ‘‘(A) nondiscrimination based upon the 

4 ability of a patient to pay; 

5 ‘‘(B) the establishment of a sliding fee 

6 scale for low-income patients; and 

7 ‘‘(C) any such services should be subject to 

8 full reimbursement according to the Prospective 

9 Payment System scale.’’. 

10 SEC. 418. FACILITATING THE PROVISION OF TELEHEALTH 

11 SERVICES ACROSS STATE LINES. 

12 (a) IN GENERAL.—For purposes of expediting the 

13 provision of telehealth services, for which payment is made 

14 under the Medicare Program, across State lines, the Sec15 retary of Health and Human Services shall, in consulta16 tion with representatives of States, physicians, health care 

17 practitioners, and patient advocates, encourage and facili18 tate the adoption of provisions allowing for multistate 

19 practitioner practice across State lines. 

20 (b) DEFINITIONS.—In subsection (a): 

21 (1) TELEHEALTH SERVICE.—The term ‘‘tele22 health service’’ has the meaning given that term in 

23 subparagraph (F) of section 1834(m)(4) of the So24 cial Security Act (42 U.S.C. 1395m(m)(4)). 


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1 (2) PHYSICIAN, PRACTITIONER.—The terms 

2 ‘‘physician’’ and ‘‘practitioner’’ have the meaning 

3 given those terms in subparagraphs (D) and (E), re4 spectively, of such section. 

5 (3) MEDICARE PROGRAM.—The term ‘‘Medicare 

6 Program’’ means the program of health insurance 

7 administered by the Secretary of Health and Human 

8 Services under title XVIII of the Social Security Act 

9 (42 U.S.C. 1395 et seq.). 

10 SEC. 419. SCORING OF PREVENTIVE HEALTH SAVINGS. 

11 Section 202 of the Congressional Budget and Im12 poundment Control Act of 1974 (2 U.S.C. 602) is amend13 ed by adding at the end the following new subsection: 

14 ‘‘(h) SCORING OF PREVENTIVE HEALTH SAVINGS.— 

15 ‘‘(1) DETERMINATION BY THE DIRECTOR.— 

16 Upon a request by the chairman or ranking minority 

17 member of the Committee on the Budget of the Sen18 ate, or by the chairman or ranking minority member 

19 of the Committee on the Budget of the House of 

20 Representatives, the Director shall determine if a 

21 proposed measure would result in reductions in 

22 budget outlays in budgetary outyears through the 

23 use of preventive health and preventive health serv24 ices. 


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1 ‘‘(2) PROJECTIONS.—If the Director determines 

2 that a measure would result in substantial reduc3 tions in budget outlays as described in paragraph 

4 (1), the Director— 

5 ‘‘(A) shall include, in any projection pre6 pared by the Director, a description and esti7 mate of the reductions in budget outlays in the 

8 budgetary outyears and a description of the 

9 basis for such conclusions; and 

10 ‘‘(B) may prepare a budget projection that 

11 includes some or all of the budgetary outyears, 

12 notwithstanding the time periods for projections 

13 described in subsection (e) and sections 308, 

14 402, and 424. 

15 ‘‘(3) DEFINITIONS.—As used in this sub16 section— 

17 ‘‘(A) the term ‘preventive health’ means an 

18 action that focuses on the health of the public, 

19 individuals, and defined populations in order to 

20 protect, promote, and maintain health, wellness, 

21 and functional ability, and prevent disease, dis22 ability, and premature death that is dem23 onstrated by credible and publicly available epi24 demiological projection models, incorporating 


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1 clinical trials or observational studies in hu2 mans, to avoid future health care costs; and 

3 ‘‘(B) the term ‘budgetary outyears’ means 

4 the 2 consecutive 10-year periods beginning 

5 with the first fiscal year that is 10 years after 

6 the budget year provided for in the most re7 cently agreed to concurrent resolution on the 

8 budget.’’. 

9 SEC. 420. SENSE OF CONGRESS ON MAINTENANCE OF EF10 FORT PROVISIONS REGARDING CHILDREN’S 

11 HEALTH. 

12 It is the sense of the Congress that— 

13 (1) the maintenance of effort provisions added 

14 to sections 1902 and 2105(d) of the Social Security 

15 Act by sections 2001(b) and 2101(b) of the Patient 

16 Protection and Affordable Care Act were written to 

17 maintain the eligibility standards for the Medicaid 

18 program under title XIX of the Social Security Act 

19 and Children’s Health Insurance Program under 

20 title XXI of such Act until the American Health 

21 Benefit Exchanges in the States are fully oper22 ational; 

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1 tended by the Congress through September 30, 

2 2022; 

3 (3) waiving the maintenance of effort provisions 

4 should not be permitted, except in the case of a re5 quest for a waiver that meets the explicit non6 application requirements; 

7 (4) the maintenance of effort provisions ensure 

8 the continued success of the Medicaid program and 

9 Children’s Health Insurance Program and were writ10 ten deliberately to specifically protect vulnerable and 

11 disabled individuals, children, and senior citizens, 

12 many of whom are also members of communities of 

13 color; and 

14 (5) the maintenance of effort provisions must 

15 be strictly enforced and proposals to weaken the 

16 maintenance of effort provisions must not be consid17 ered. 

18 SEC. 421. REPEAL OF REQUIREMENT FOR DOCUMENTA19 TION EVIDENCING CITIZENSHIP OR NATION20 ALITY UNDER THE MEDICAID PROGRAM. 

21 (a) REPEAL.—Subsections (i)(22) and (x) of section 

22 1903 of the Social Security Act (42 U.S.C. 1396b) are 

23 each repealed. 

24 (b) CONFORMING AMENDMENTS.— 


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1 (1) Section 1902 of the Social Security Act (42 

2 U.S.C. 1396a) is amended— 

3 (A) by amending paragraph (46) of sub4 section (a) to read as follows: 

5 ‘‘(46) provide that information is requested and 

6 exchanged for purposes of income and eligibility 

7 verification in accordance with a State system which 

8 meets the requirements of section 1137 of this 

9 Act;’’; 

10 (B) in subsection (e)(13)(A)(i)— 

11 (i) in the matter preceding subclause 

12 (I), by striking ‘‘sections 1902(a)(46)(B) 

13 and 1137(d)’’ and inserting ‘‘section 

14 1137(d)’’; and 

15 (ii) in subclause (IV), by striking 

16 ‘‘1902(a)(46)(B) or’’; and 

17 (C) by striking subsection (ee). 

18 (2) Section 1903 of the Social Security Act (42 

19 U.S.C. 1396b) is amended— 

20 (A) in subsection (i), by redesignating 

21 paragraphs (23) through (26) as paragraphs 

22 (22) through (25), respectively; and 

23 (B) by redesignating subsections (y) and 

24 (z) as subsections (x) and (y), respectively. 


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1 (3) Subsection (c) of section 6036 of the Deficit 

2 Reduction Act of 2005 (42 U.S.C. 1396b note) is re3 pealed. 

4 (c) EFFECTIVE DATE.—The repeals and amend5 ments made by this section shall take effect as if included 

6 in the enactment of the Deficit Reduction Act of 2005. 

7 SEC. 422. PROTECTION OF THE HHS OFFICES OF MINORITY 

8 HEALTH. 

9 (a) IN GENERAL.—Pursuant to the Patient Protec10 tion and Affordable Care Act (Public Law 111–148), the 

11 Offices of Minority Health established within the Centers 

12 for Disease Control and Prevention, the Health Resources 

13 and Services Administration, the Substance Abuse and 

14 Mental Health Services Administration, the Agency for 

15 Healthcare Research and Quality, the Food and Drug Ad16 ministration, and the Centers for Medicare & Medicaid 

17 Services, are offices that, regardless of change in the 

18 structure of the Department of Health and Human Serv19 ices, shall report to the Secretary of Health and Human 

20 Services. 

21 (b) SENSE OF CONGRESS.—It is the sense of the 

22 Congress that any effort to eliminate or consolidate such 

23 Offices of Minority Health undermines the progress 

24 achieved so far. 


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1 SEC. 423. OFFICE OF MINORITY HEALTH IN VETERANS 

2 HEALTH ADMINISTRATION OF DEPARTMENT 

3 OF VETERANS AFFAIRS. 

4 (a) ESTABLISHMENT AND FUNCTIONS.—Subchapter 

5 I of chapter 73 of title 38, United States Code, is amended 

6 by adding at the end the following new section: 

7 ‘‘§ 7310. Office of Minority Health 

8 ‘‘(a) ESTABLISHMENT.—There is established in the 

9 Department within the Office of the Under Secretary for 

10 Health an office to be known as the ‘Office of Minority 

11 Health’ (in this section referred to as the ‘Office’). 

12 ‘‘(b) HEAD.—The Director of the Office of Minority 

13 Health shall be the head of the Office. The Director of 

14 the Office of Minority Health shall be appointed by the 

15 Under Secretary of Health from among individuals quali16 fied to perform the duties of the position. 

17 ‘‘(c) FUNCTIONS.—The functions of the Office are as 

18 follows: 

19 ‘‘(1) To establish short-range and long-range 

20 goals and objectives and coordinate all other activi21 ties within the Veterans Health Administration that 

22 relate to disease prevention, health promotion, health 

23 care services delivery, and health care research con24 cerning veterans who are members of a racial or eth25 nic minority group. 


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1 ‘‘(2) To support research, demonstrations, and 

2 evaluations to test new and innovative models for 

3 the discharge of activities described in paragraph 

4 (1). 

5 ‘‘(3) To increase knowledge and understanding 

6 of health risk factors for veterans who are members 

7 of a racial or ethnic minority group. 

8 ‘‘(4) To develop mechanisms that support bet9 ter health care information dissemination, education, 

10 prevention, and services delivery to veterans from 

11 disadvantaged backgrounds, including veterans who 

12 are members of a racial or ethnic minority group. 

13 ‘‘(5) To enter into contracts or agreements with 

14 appropriate public and nonprofit private entities to 

15 develop and carry out programs to provide bilingual 

16 or interpretive services to assist veterans who are 

17 members of a racial or ethnic minority group and 

18 who lack proficiency in speaking the English lan19 guage in accessing and receiving health care services 

20 through the Veterans Health Administration. 

21 ‘‘(6) To carry out programs to improve access 

22 to health care services through the Veterans Health 

23 Administration for veterans with limited proficiency 

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1 velopment and evaluation of demonstration and pilot 

2 projects for that purpose. 

3 ‘‘(7) To advise the Under Secretary of Health 

4 on matters relating to the development, implementa5 tion, and evaluation of health professions education 

6 in decreasing disparities in health care outcomes be7 tween veterans who are members of a racial or eth8 nic minority group and other veterans, including cul9 tural competency as a method of eliminating such 

10 health disparities. 

11 ‘‘(8) To perform such other functions and du12 ties as the Secretary or the Under Secretary for 

13 Health considers appropriate. 

14 ‘‘(d) DEFINITIONS.—In this section: 

15 ‘‘(1) The term ‘racial or ethnic minority group’ 

16 means any of the following: 

17 ‘‘(A) American Indians (including Alaska 

18 Natives, Eskimos, and Aleuts). 

19 ‘‘(B) Asian Americans. 

20 ‘‘(C) Native Hawaiians and other Pacific 

21 Islanders. 

22 ‘‘(D) Blacks. 

23 ‘‘(E) Hispanics. 

24 ‘‘(2) The term ‘Hispanic’ means individuals 

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1 tral or South American, or any other Spanish-speak2 ing country.’’. 

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

4 at the beginning of such chapter is amended by inserting 

5 after the item relating to section 7309A the following new 

6 item: 

‘‘7310. Office of Minority Health.’’. 

7 SEC. 424. INDIAN DEFINED IN PPACA. 

8 (a) DEFINITION OF INDIAN.—Section 1304 of the 

9 Patient Protection and Affordable Care Act (42 U.S.C. 

10 18024) is amended by adding at the end the following: 

11 ‘‘(f) INDIAN.— 

12 ‘‘(1) IN GENERAL.—In this title, the term ‘In13 dian’ means any individual— 

14 ‘‘(A) described in paragraph (13) or (28) 

15 of section 4 of the Indian Health Care Improve16 ment Act (25 U.S.C. 1603); 

17 ‘‘(B) who is eligible for health services pro18 vided by the Indian Health Service under sec19 tion 809 of the Indian Health Care Improve20 ment Act (25 U.S.C. 1679); 

21 ‘‘(C) who is of Indian descent and belongs 

22 to the Indian community served by the local fa23 cilities and program of the Indian Health Serv24 ice; or 

25 ‘‘(D) who is described in paragraph (2). 


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1 ‘‘(2) INCLUDED INDIVIDUALS.—The following 

2 individuals shall be considered to be an ‘Indian’: 

3 ‘‘(A) A member of a federally recognized 

4 Indian Tribe. 

5 ‘‘(B) A resident of an urban center who 

6 meets 1 or more of the following 4 criteria: 

7 ‘‘(i) Membership in a Tribe, band, or 

8 other organized group of Indians, including 

9 those Tribes, bands, or groups terminated 

10 since 1940 and those recognized as of the 

11 date of enactment of the Health Equity 

12 and Accountability Act of 2018 or later by 

13 the State in which they reside, or being a 

14 descendant, in the first or second degree, 

15 of any such member. 

16 ‘‘(ii) Is an Eskimo or Aleut or other 

17 Alaska Native. 

18 ‘‘(iii) Is considered by the Secretary of 

19 the Interior to be an Indian for any pur20 pose. 

21 ‘‘(iv) Is determined to be an Indian 

22 under regulations promulgated by the Sec23 retary. 


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1 ‘‘(C) An individual who is considered by 

2 the Secretary of the Interior to be an Indian for 

3 any purpose. 

4 ‘‘(D) An individual who is considered by 

5 the Secretary to be an Indian for purposes of 

6 eligibility for Indian health care services, includ7 ing as a California Indian, Eskimo, Aleut, or 

8 other Alaska Native.’’. 

9 (b) CONFORMING AMENDMENTS.— 

10 (1) AFFORDABLE CHOICES HEALTH BENEFIT

11 PLANS.—Section 1311(c)(6)(D) of the Patient Pro12 tection and Affordable Care Act (42 U.S.C. 

13 18031(c)(6)(D)) is amended by striking ‘‘section 4 

14 of the Indian Health Care Improvement Act’’ and 

15 inserting ‘‘section 1304(f)’’. 

16 (2) REDUCED COST-SHARING FOR INDIVIDUALS

17 ENROLLING IN QUALIFIED HEALTH PLANS.—Section 

18 1402(d) of the Patient Protection and Affordable 

19 Care Act (42 U.S.C. 18071(d)) is amended— 

20 (A) in paragraph (1), in the matter pre21 ceding subparagraph (A), by striking ‘‘section 

22 4(d) of the Indian Self-Determination and Edu23 cation Assistance Act (25 U.S.C. 450b(d))’’ and 

24 inserting ‘‘section 1304(f)’’; and 


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1 (B) in paragraph (2), in the matter pre2 ceding subparagraph (A), by striking ‘‘(as so 

3 defined)’’ and inserting ‘‘(as defined in section 

4 1304(f))’’. 

5 (3) EXEMPTION FROM PENALTY FOR NOT

6 MAINTAINING MINIMUM ESSENTIAL COVERAGE.— 

7 Section 5000A(e) of the Internal Revenue Code of 

8 1986 is amended by striking paragraph (3) and in9 serting the following: 

10 ‘‘(3) INDIANS.—Any applicable individual who 

11 is an Indian (as defined in section 1304(f) of the 

12 Patient Protection and Affordable Care Act).’’. 

13 SEC. 425. STUDY OF DSH PAYMENTS TO ENSURE HOSPITAL 

14 ACCESS FOR LOW-INCOME PATIENTS. 

15 (a) IN GENERAL.—Not later than January 1, 2019, 

16 the Comptroller General of the United States shall con17 duct a study on how certain amendments made by the Pa18 tient Protection and Affordable Care Act (Public Law 

19 111–148) to titles XVIII and XIX of the Social Security 

20 Act affect the timely access to health care services for low21 income patients. Such study shall— 

22 (1) evaluate and examine whether States elect23 ing to make medical assistance available under sec24 tion 1902(a)(10)(A)(i)(VIII) of the Social Security 

25 Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) (including 


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1 States making such an election through a waiver of 

2 the State plan) to individuals described in such sec3 tion mitigates the need for payments to dispropor4 tionate share hospitals under section 1886(d)(5)(F) 

5 of the Social Security Act (42 U.S.C. 

6 1395ww(d)(5)(F)) and section 1923 of such Act (42 

7 U.S.C. 1396r–4), including the impact of such 

8 States electing to make medical assistance available 

9 to such individuals on— 

10 (A) the number of individuals in the 

11 United States who are without health insurance 

12 and the distribution of such individuals in rela13 tion to areas primarily served by dispropor14 tionate share hospitals; and 

15 (B) the low-income utilization rate of such 

16 hospitals and the resulting fiscal sustainability 

17 of such hospitals; 

18 (2) evaluate the appropriate level and distribu19 tion of such payments among disproportionate hos20 pitals for purposes of— 

21 (A) sufficiently accounting for the level of 

22 uncompensated care provided by such hospitals 

23 to low-income patients; and 


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1 (B) providing timely access to health serv2 ices for individuals in medically underserved 

3 areas; and 

4 (3) assess, with respect to disproportionate hos5 pitals— 

6 (A) the role played by such hospitals in 

7 providing critical access to emergency, inpa8 tient, and outpatient health services, as well as 

9 the location of such hospitals in relation to 

10 medically underserved areas; and 

11 (B) the extent to which such hospitals sat12 isfy the requirements established for charitable 

13 hospital organizations under section 501(r) of 

14 the Internal Revenue Code of 1986 with respect 

15 to community health needs assessments, finan16 cial assistance policy requirements, limitations 

17 on charges, and billing and collection require18 ments. 

19 (b) REPORTS.— 

20 (1) REPORT TO CONGRESS.—Not later than 

21 180 days after the date on which the study under 

22 subsection (a) is completed, the Comptroller General 

23 of the United States shall submit to the Committee 

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1 cation, Labor, and Pensions of the Senate a report 

2 that contains— 

3 (A) the results of the study; 

4 (B) recommendations to Congress for any 

5 legislative changes to the payments to dis6 proportionate share hospitals under section 

7 1886(d)(5)(F) of the Social Security Act (42 

8 U.S.C. 1395ww(d)(5)(F)) and section 1923 of 

9 such Act (42 U.S.C. 1396r–4) that are needed 

10 to ensure access to health services for low-in11 come patients that— 

12 (i) are based on the number of indi13 viduals without health insurance, the 

14 amount of uncompensated care provided by 

15 such hospitals, and the impact of reduced 

16 payments levels on low-income commu17 nities; and 

18 (ii) takes into account any reports 

19 submitted by the Secretary of the Treas20 ury, in consultation with the Secretary of 

21 Health and Human Services, to Congres22 sional committees regarding the costs in23 curred by charitable hospital organizations 

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1 uals under the Medicare Program under 

2 title XVIII of the Social Security Act and 

3 the Medicaid Program under title XIX of 

4 such Act, and any community benefit ac5 tivities provided by such organizations. 

6 (2) REPORT TO THE SECRETARY OF HEALTH

7 AND HUMAN SERVICES.—Not later than 180 days 

8 after the date on which the study under subsection 

9 (a) is completed, the Comptroller General of the 

10 United States shall submit to the Secretary of 

11 Health and Human Services a report that con12 tains— 

13 (A) the results of the study; and 

14 (B) any recommendations for purposes of 

15 assisting in the development of the methodology 

16 for the adjustment of payments to dispropor17 tionate share hospitals, as required under sec18 tion 1886(r) of the Social Security Act (42 

19 U.S.C. 1395ww(r)) and the reduction of such 

20 payments section 1923(f)(7) of such Act (42 

21 U.S.C. 1396r–4(f)(7)), taking into account the 

22 reports referred to in paragraph (1)(B)(ii). 


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1 SEC. 426. ASSISTANT SECRETARY OF THE INDIAN HEALTH 

2 SERVICE. 

3 (a) REFERENCES.—Any reference in a law, regula4 tion, document, paper, or other record of the United 

5 States to the Director of the Indian Health Service shall 

6 be deemed to be a reference to the Assistant Secretary 

7 of the Indian Health Service. 

8 (b) EXECUTIVE SCHEDULE.—Section 5315 of title 5, 

9 United States Code, is amended in the matter relating to 

10 the Assistant Secretaries of Health and Human Services 

11 by striking ‘‘(6)’’ and inserting ‘‘(7), 1 of whom shall be 

12 the Assistant Secretary of the Indian Health Service’’. 

13 (c) CONFORMING AMENDMENT.—Section 5316 of 

14 title 5, United States Code, is amended by striking ‘‘Direc15 tor, Indian Health Service, Department of Health and 

16 Human Services.’’. 

17 SEC. 427. REAUTHORIZATION OF THE NATIVE HAWAIIAN 

18 HEALTH CARE IMPROVEMENT ACT. 

19 (a) NATIVE HAWAIIAN HEALTH CARE SYSTEMS.— 

20 Section 6(h)(1) of the Native Hawaiian Health Care Im21 provement Act (42 U.S.C. 11705(h)(1)) is amended by 

22 striking ‘‘may be necessary for fiscal years 1993 through 

23 2019’’ and inserting ‘‘are necessary’’. 

24 (b) ADMINISTRATIVE GRANT FOR PAPA OLA

25 LOKAHI.—Section 7(b) of the Native Hawaiian Health 

26 Care Improvement Act (42 U.S.C. 11706(b)) is amended 


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1 by striking ‘‘may be necessary for fiscal years 1993 

2 through 2019’’ and inserting ‘‘are necessary’’. 

3 (c) NATIVE HAWAIIAN HEALTH SCHOLARSHIPS.— 

4 Section 10(c) of the Native Hawaiian Health Care Im5 provement Act (42 U.S.C. 11709(c)) is amended by strik6 ing ‘‘may be necessary for fiscal years 1993 through 

7 2019’’ and inserting ‘‘are necessary’’. 

8 SEC. 428. AVAILABILITY OF NON-ENGLISH LANGUAGE 

9 SPEAKING PROVIDERS. 

10 (a) IN GENERAL.—Section 1311(c)(1)(B) of the Pa11 tient Protection and Affordable Care Act (42 U.S.C. 

12 18031(c)(1)(B)) is amended by inserting before the semi13 colon the following: ‘‘and, with respect to such providers, 

14 a provider’s ability to provide care in a language other 

15 than English either through the provider speaking such 

16 language or by the provider having a trained medical in17 terpreter, as defined in subsection (b) of this section, who 

18 speaks such language available during office hours’’. 

19 (b) QUALIFIED INTERPRETER FOR AN INDIVIDUAL

20 WITH LIMITED-ENGLISH PROFICIENCY, DEFINED.—The 

21 term ‘‘Qualified interpreter for an individual with limited22 English proficiency’’ means an interpreter who via a re23 mote interpreting service or an on-site appearance— 

24 (1) adheres to generally accepted interpreter 

25 ethics principles, including client confidentiality; 


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1 (2) has demonstrated proficiency in speaking 

2 and understanding both spoken English and at least 

3 one other spoken language; and 

4 (3) is able to interpret effectively, accurately, 

5 and impartially, both receptively and expressly, to 

6 and from such language(s) and English, using any 

7 necessary specialized vocabulary, terminology and 

8 phraseology. 

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

10 subsection (a) shall apply for plan years beginning more 

11 than 1 year after the date of the enactment of this Act. 

12 SEC. 429. ACCESS TO ESSENTIAL COMMUNITY PROVIDERS. 

13 (a) ESSENTIAL COMMUNITY PROVIDERS.—Section 

14 1311(c)(1)(C) of the Patient Protection and Affordable 

15 Care Act (42 U.S.C. 18031(c)(1)(C)) is amended— 

16 (1) by inserting ‘‘(i)’’ after ‘‘(C)’’; and 

17 (2) by adding at the end the following new 

18 clauses: 

19 ‘‘(ii) not later than 2018, increase the per20 centage of essential community providers in21 cluded in its network by 10 percent annually 

22 (based on the level in the plan for 2016) until 

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1 munity providers in the contract service area 

2 are in-network; and 

3 ‘‘(iii) include one of each type of essential 

4 community provider in network in each county 

5 in their service area, where available;’’. 

6 (b) REPORTING REQUIREMENTS.—Section 

7 1311(e)(3) of the Patient Protection and Affordable Care 

8 Act (42 U.S.C. 18031(e)(3)(A)) is amended by adding at 

9 the end the following new subparagraph: 

10 ‘‘(E) DATA ON ESSENTIAL COMMUNITY

11 PROVIDERS.—The Secretary shall require quali12 fied health plans to submit annually to the Sec13 retary data on the percentage of essential com14 munity providers, by county, that contract with 

15 each qualified health plan offered in that county 

16 and the percentage of essential community pro17 viders, by type, that contract with each quali18 fied health plan offered in that county. Data so 

19 submitted shall be made available to the general 

20 public’’. 

21 (c) ESSENTIAL COMMUNITY PROVIDER PROVISIONS

22 APPLIED UNDER MEDICARE AND MEDICAID.— 

23 (1) MEDICARE.—Section 1852(d)(1) of the So24 cial Security Act (42 U.S.C.1395w–22(d)(1)) is 

25 amended— 


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1 (A) by striking ‘‘and’’ at the end of sub2 paragraph (D); 

3 (B) by striking the period at the end of 

4 subparagraph (E) and inserting ‘‘; and’’; and 

5 (C) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(F) the plan meets the requirements of 

8 clauses (ii) and (iii) of section 1311(c)(1)(C) of 

9 the Patient Protection and Affordable Care Act 

10 (relating to inclusion in networks of essential 

11 community providers).’’. 

12 (2) MEDICAID.—Section 1932(b)(5) of the So13 cial Security Act (42 U.S.C. 1396u–2(b)(5)) is 

14 amended— 

15 (A) by striking ‘‘and’’ at the end of sub16 paragraph (A); 

17 (B) by striking the period at the end of 

18 subparagraph (B) and inserting ‘‘; and’’; and 

19 (C) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(C) the plan meets the requirements of 

22 clauses (ii) and (iii) of section 1311(c)(1)(C) of 

23 the Patient Protection and Affordable Care Act 

24 (relating to inclusion in networks of essential 


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1 community providers) with respect to services 

2 offered in the service area involved.’’. 

3 SEC. 430. PROVIDER NETWORK ADEQUACY IN COMMU4 NITIES OF COLOR. 

5 (a) IN GENERAL.—Section 1311(c)(1)(B) of the Pa6 tient Protection and Affordable Care Act (42 U.S.C. 

7 18031(c)(1)(B)) is amended— 

8 (1) by inserting ‘‘(i)’’ after ‘‘(B)’’; and 

9 (2) by adding at the end the following the fol10 lowing new clauses: 

11 ‘‘(ii) meet such network adequacy 

12 standards as the Secretary may establish 

13 with regard to— 

14 ‘‘(I) appointment wait time; 

15 ‘‘(II) travel time and distance to 

16 health care provider facilities and pro17 viders by public and private transit; 

18 ‘‘(III) hours of operation to ac19 commodate individuals who cannot 

20 come to provider appointments during 

21 standard business hours; and 

22 ‘‘(IV) other network adequacy 

23 standards to ensure that care through 

24 these plans is accessible to diverse 


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1 communities, including those who are 

2 limited-English proficient; and 

3 ‘‘(iii) provide coverage for services for 

4 enrollees through out-of-network providers 

5 at no additional cost to the enrollees in 

6 cases where in-network providers are un7 able to comply with the standards estab8 lished under clause subclause (III) or (IV) 

9 of clause (ii) for such services and the out10 of-network providers can deliver such serv11 ices in compliance with such standards. 

12 ‘‘(b) EFFECTIVE DATE.—The amendments made by 

13 subsection (a) shall apply to plan years beginning more 

14 than 1 year after the date of the enactment of this Act.’’. 

15 SEC. 431. IMPROVING ACCESS TO DENTAL CARE. 

16 (a) REPORTS TO CONGRESS.— 

17 (1) GAO REPORT ON DENTAL THERAPIST PRO18 GRAMS.—Not later than 1 year after the date of the 

19 enactment of this Act, the Comptroller General of 

20 the United States shall submit to Congress a report 

21 on the Alaska Dental Health Aide Therapists Pro22 gram and the Dental Therapist and Advanced Den23 tal Therapist programs in Minnesota, to assess den24 tal therapists’ effectiveness in— 


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1 (A) improving access to timely dental care 

2 among communities of color; 

3 (B) providing high quality care; and 

4 (C) providing culturally competent care. 

5 (2) GAO REPORT OF EXPANDING SCOPE OF

6 CERTAIN PRACTICES.—The GAO shall also report on 

7 state variations in use of dental hygienists and as8 sess the effectiveness of expanding the scope of prac9 tice for hygienists in— 

10 (A) improving access to timely dental care 

11 among communities of color; 

12 (B) providing high quality care; and 

13 (C) providing culturally competent care. 

14 (3) HRSA REPORT ON DENTAL SHORTAGE

15 AREAS.—Not later than 1 year after the date of the 

16 enactment of this Act, the Secretary, acting through 

17 the Administrator of the Health Resources Service 

18 Administration, shall submit to Congress a report 

19 which details geographic dental access shortages and 

20 the preparedness of dental providers to offer cul21 turally and linguistically appropriate, affordable, ac22 cessible, and timely services. 

23 (b) EXPANSION OF DENTAL HEALTH AID THERA24 PISTS IN TRIBAL COMMUNITIES.—Section 119(d) of the 


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1 Indian Health Care Improvement Act ( U.S.C. 1616l(d)) 

2 is amended— 

3 (1) in paragraph (2), by striking ‘‘Subject to’’ 

4 and all that follows and inserting ‘‘Subject to para5 graph (3), in establishing a national program under 

6 paragraph (1), the Secretary shall not reduce the 

7 amounts provided for the Community Health Aide 

8 Program described in subsections (a) and (b).’’; 

9 (2) by striking paragraph (3); and 

10 (3) by redesignating paragraph (4) as para11 graph (3). 

12 (c) COVERAGE OF DENTAL SERVICES UNDER THE

13 MEDICARE PROGRAM.— 

14 (1) COVERAGE.—Section 1861(s)(2) of the So15 cial Security Act (42 U.S.C. 1395x(s)(2)) is amend16 ed— 

17 (A) in subparagraph (EE), by striking 

18 ‘‘and’’ after the semicolon at the end; 

19 (B) in subparagraph (FF), by adding 

20 ‘‘and’’ after the semicolon at the end; and 

21 (C) by adding at the end the following new 

22 subparagraph: 

23 ‘‘(GG) oral health services (as defined in 

24 subsection (kkk);’’. 


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1 (2) ORAL HEALTH SERVICES DEFINED.—Sec2 tion 1861 of the Social Security Act (42 U.S.C. 

3 1395x), as amended by sections 205(b) and 433(a), 

4 is amended by adding at the end the following new 

5 subsection: 

6 ‘‘Oral Health Services 

7 ‘‘(kkk)(1) The term ‘oral health services’ means serv8 ices (as defined by the Secretary) that are necessary to 

9 prevent disease and promote oral health, restore oral 

10 structures to health and function, and treat emergency 

11 conditions. 

12 ‘‘(2) For purposes of paragraph (1), such term shall 

13 include mobile and portable oral health services (as de14 fined by the Secretary) that— 

15 ‘‘(A) are provided for the purpose of over16 coming mobility, transportation, and access barriers 

17 for individuals; and 

18 ‘‘(B) satisfy the standards and certification re19 quirements established under section 1902(a)(82)(B) 

20 for the State in which the services are provided.’’. 

21 (3) PAYMENT AND COINSURANCE.—Section 

22 1833(a)(1) of the Social Security Act (42 U.S.C. 

23 1395l(a)(1)) is amended— 

24 (A) by striking ‘‘and’’ before ‘‘(Z)’’; and 


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1 (B) by inserting before the semicolon at 

2 the end the following: ‘‘, and (AA) with respect 

3 to oral health services (as defined in section 

4 1861(kkk)), the amount paid shall be (i) in the 

5 case of such services that are preventive, 100 

6 percent of the lesser of the actual charge for 

7 the services or the amount determined under 

8 the payment basis determined under section 

9 1848, and (ii) in the case of all other such serv10 ices, 80 percent of the lesser of the actual 

11 charge for the services or the amount deter12 mined under the payment basis determined 

13 under section 1848’’. 

14 (4) PAYMENT UNDER PHYSICIAN FEE SCHED15 ULE.—Section 1848(j)(3) of the Social Security Act 

16 (42 U.S.C. 1395w–4(j)(3)) is amended by inserting 

17 ‘‘(2)(GG),’’ after ‘‘risk assessment),’’. 

18 (5) DENTURES.—Section 1861(s)(8) of the So19 cial Security Act (42 U.S.C. 1395x(s)(8)) is amend20 ed— 

21 (A) by striking ‘‘(other than dental)’’ and 

22 inserting ‘‘(including dentures)’’; and 

23 (B) by striking ‘‘internal body’’. 

24 (6) REPEAL OF GROUND FOR EXCLUSION.— 

25 Section 1862(a) of the Social Security Act (42 


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1 U.S.C. 1395y) is amended by striking paragraph 

2 (12). 

3 (7) EFFECTIVE DATE.—The amendments made 

4 by this section shall apply to services furnished on 

5 or after January 1, 2019. 

6 (d) COVERAGE OF DENTAL SERVICES UNDER THE

7 MEDICAID PROGRAM.— 

8 (1) IN GENERAL.—Section 1905 of the Social 

9 Security Act (42 U.S.C. 1396d) is amended— 

10 (A) in subsection (a)(10), by striking ‘‘den11 tal services’’ and inserting ‘‘oral health services 

12 (as defined in subsection (ee)(1))’’; and 

13 (B) by adding at the end the following new 

14 subsection: 

15 ‘‘(ee)(1) Subject to paragraphs (2) and (3), for pur16 poses of this title, the term ‘oral health services’ means 

17 services (as defined by the Secretary) that are necessary 

18 to prevent disease and promote oral health, restore oral 

19 structures to health and function, and treat emergency 

20 conditions. These services shall include, in the case of 

21 pregnant or postpartum women, such services as are nec22 essary to address oral health conditions that exist or are 

23 exacerbated by pregnancy or childbirth or which, if left 

24 untreated, could adversely affect fetal or child develop25 ment. 


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1 ‘‘(2) For purposes of paragraph (1), such term shall 

2 include— 

3 ‘‘(A) dentures; and 

4 ‘‘(B) mobile and portable oral health services 

5 (as defined by the Secretary) that— 

6 ‘‘(i) are provided for the purpose of over7 coming mobility, transportation, and access bar8 riers for individuals; and 

9 ‘‘(ii) satisfy the standards and certification 

10 requirements established under section 

11 1902(a)(82)(C) for the State in which the serv12 ices are provided. 

13 ‘‘(3) For purposes of paragraph (1), such term shall 

14 not apply to dental care or services provided to individuals 

15 under the age of 21 under subsection (r)(3).’’. 

16 (2) CONFORMING AMENDMENTS.— 

17 (A) STATE PLAN REQUIREMENTS.—Section 

18 1902(a) of the Social Security Act (42 U.S.C. 

19 1396a(a)) is amended— 

20 (i) in paragraph (10)(A), in the mat21 ter preceding clause (i), by inserting 

22 ‘‘(10),’’ after ‘‘(5),’’; 

23 (ii) in paragraph (80), by striking 

24 ‘‘and’’ at the end; 


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1 (iii) in paragraph (81), by striking the 

2 period at the end and inserting ‘‘; and’’; 

3 and 

4 (iv) by inserting after paragraph (81) 

5 the following: 

6 ‘‘(82) provide for— 

7 ‘‘(A) informing, in writing, all individuals 

8 who have been determined to be eligible for 

9 medical assistance of the availability of oral 

10 health services (as defined in section 1905(ee)); 

11 ‘‘(B) conducting targeted outreach to preg12 nant women who have been determined to be el13 igible for medical assistance about the avail14 ability of medical assistance for such dental 

15 services and the importance of receiving dental 

16 care while pregnant; and 

17 ‘‘(C) establishing and maintaining stand18 ards for and certification of mobile and portable 

19 oral health services (as described in subsections 

20 (r)(3)(C) and (ee)(2)(B) of section 1905).’’. 

21 (B) DEFINITION OF MEDICAL ASSIST22 ANCE.—Section 1905(a)(12) of the Social Secu23 rity Act (42 U.S.C. 1396d(a)(12)) is amended 

24 by striking ‘‘, dentures,’’. 


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1 (3) MOBILE AND PORTABLE ORAL HEALTH

2 SERVICES UNDER EPSDT.—Section 1905(r)(3) of the 

3 Social Security Act (42 U.S.C. 1396d(r)(3)) is 

4 amended— 

5 (A) in subparagraph (A)(ii), by striking ‘‘; 

6 and’’ and inserting a semicolon; 

7 (B) in subparagraph (B), by striking the 

8 period at the end and inserting ‘‘; and’’; and 

9 (C) by adding at the end the following new 

10 subparagraph: 

11 ‘‘(C) which shall include mobile and port12 able oral health services (as defined by the Sec13 retary) that— 

14 ‘‘(i) are provided for the purpose of 

15 overcoming mobility, transportation, or ac16 cess barriers for children; and 

17 ‘‘(ii) satisfy the standards and certifi18 cation requirements established under sec19 tion 1902(a)(82)(C) for the State in which 

20 the services are provided.’’. 

21 (e) ORAL HEALTH SERVICES AS AN ESSENTIAL

22 HEALTH BENEFIT.—Section 1302(b) of the Patient Pro23 tection and Affordable Care Act (42 U.S.C. 18022(b)) is 

24 amended— 

25 (1) in paragraph (1)— 


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1 (A) in subparagraph (J), by striking ‘‘oral 

2 and’’; and 

3 (B) by adding at the end the following: 

4 ‘‘(K) Oral health services for children and 

5 adults.’’; and 

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

7 ‘‘(6) ORAL HEALTH SERVICES.—For purposes 

8 of paragraph (1)(K), the term ‘oral health services’ 

9 means services (as defined by the Secretary), that 

10 are necessary to prevent disease and promote oral 

11 health, restore oral structures to health and func12 tion, and treat emergency conditions.’’. 

13 (f) DEMONSTRATION PROGRAM ON TRAINING AND

14 EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE

15 PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR

16 VETERANS IN RURAL AND OTHER UNDERSERVED COM17 MUNITIES.— 

18 (1) DEMONSTRATION PROGRAM AUTHORIZED.— 

19 The Secretary of Veterans Affairs may carry out a 

20 demonstration program to establish programs to 

21 train and employ alternative dental health care pro22 viders in order to increase access to dental health 

23 care services for veterans who are entitled to such 

24 services from the Department of Veterans Affairs 


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1 and reside in rural and other underserved commu2 nities. 

3 (2) TELEHEALTH.—For purposes of alternative 

4 dental health care providers and other dental care 

5 providers who are licensed to provide clinical care, 

6 dental services provided under the demonstration 

7 program under this section may be administered by 

8 such providers through telehealth-enabled collabora9 tion and supervision when appropriate and feasible. 

10 (3) ALTERNATIVE DENTAL HEALTH CARE PRO11 VIDERS DEFINED.—In this section, the term ‘‘alter12 native dental health care providers’’ has the meaning 

13 given that term in section 340G–1(a)(2) of the Pub14 lic Health Service Act (42 U.S.C. 256g–1(a)(2)). 

15 (4) AUTHORIZATION OF APPROPRIATIONS.— 

16 There are authorized to be appropriated such sums 

17 as are necessary to carry out the demonstration pro18 gram under this subsection. 

19 (g) DEMONSTRATION PROGRAM ON TRAINING AND

20 EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE

21 PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR

22 MEMBERS OF THE ARMED FORCES AND DEPENDENTS

23 LACKING READY ACCESS TO SUCH SERVICES.— 

24 (1) DEMONSTRATION PROGRAM AUTHORIZED.— 

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1 onstration program to establish programs to train 

2 and employ alternative dental health care providers 

3 in order to increase access to dental health care 

4 services for members of the Armed Forces and their 

5 dependents who lack ready access to such services, 

6 including the following: 

7 (A) Members and dependents who reside in 

8 rural areas or areas otherwise underserved by 

9 dental health care providers. 

10 (B) Members of the National Guard and 

11 Reserves in active status who are potentially 

12 deployable. 

13 (2) TELEHEALTH.—For purposes of alternative 

14 dental health care providers and other dental care 

15 providers who are licensed to provide clinical care, 

16 dental services provided under the demonstration 

17 program under this section may be administered by 

18 such providers through telehealth-enabled collabora19 tion and supervision when appropriate and feasible. 

20 (3) ALTERNATIVE DENTAL HEALTH CARE PRO21 VIDERS DEFINED.—In this section, the term ‘‘alter22 native dental health care providers’’ has the meaning 

23 given that term in section 340G–1(a)(2) of the Pub24 lic Health Service Act (42 U.S.C. 256g–1(a)(2)). 


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1 (4) AUTHORIZATION OF APPROPRIATIONS.— 

2 There are authorized to be appropriated such sums 

3 as are necessary to carry out the demonstration pro4 gram under this subsection. 

5 (h) DEMONSTRATION PROGRAM ON TRAINING AND

6 EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE

7 PROVIDERS FOR DENTAL HEALTH CARE SERVICES FOR

8 PRISONERS WITHIN THE CUSTODY OF THE BUREAU OF

9 PRISONS.— 

10 (1) DEMONSTRATION PROGRAM AUTHORIZED.— 

11 The Attorney General, acting through the Director 

12 of the Bureau of Prisons, may carry out a dem13 onstration program to establish programs to train 

14 and employ alternative dental health care providers 

15 in order to increase access to dental health services 

16 for prisoners within the custody of the Bureau of 

17 Prisons. 

18 (2) TELEHEALTH.—For purposes of alternative 

19 dental health care providers and any other dental 

20 care providers who are licensed to provide clinical 

21 care, dental services provided under the demonstra22 tion program under this section may be administered 

23 by such providers through telehealth-enabled collabo24 ration and supervision when deemed appropriate and 

25 feasible. 


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1 (3) ALTERNATIVE DENTAL HEALTH CARE PRO2 VIDERS DEFINED.—In this section, the term ‘‘alter3 native dental health care providers’’ has the meaning 

4 given that term in section 340G–1(a)(2) of the Pub5 lic Health Service Act (42 U.S.C. 256g–1(a)(2)). 

6 (4) AUTHORIZATION OF APPROPRIATIONS.— 

7 There are authorized to be appropriated such sums 

8 as are necessary to carry out the demonstration pro9 gram under this subsection. 

10 (i) DEMONSTRATION PROGRAM ON TRAINING AND

11 EMPLOYMENT OF ALTERNATIVE DENTAL HEALTH CARE

12 PROVIDERS FOR DENTAL HEALTH CARE SERVICES

13 UNDER THE INDIAN HEALTH SERVICE.— 

14 (1) DEMONSTRATION PROGRAM AUTHORIZED.— 

15 The Secretary of Health and Human Services, act16 ing through the Indian Health Service, may carry 

17 out a demonstration program to establish programs 

18 to train and employ alternative dental health care 

19 providers in order to help eliminate oral health dis20 parities and increase access to dental services 

21 through health programs operated by the Indian 

22 Health Service, Indian Tribes, Tribal organizations, 

23 and urban Indian organizations (as those terms are 

24 defined in section 4 of the Indian Health Care Im25 provement Act (25 U.S.C. 1603)). 


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1 (2) TELEHEALTH.—For purposes of alternative 

2 dental health care providers and any other dental 

3 care providers who are licensed to provide clinical 

4 care, dental services provided under the demonstra5 tion program under this section may be administered 

6 by such providers through telehealth-enabled collabo7 ration and supervision when deemed appropriate and 

8 feasible. 

9 (3) ALTERNATIVE DENTAL HEALTH CARE PRO10 VIDERS DEFINED.—In this section, the term ‘‘alter11 native dental health care providers’’ has the meaning 

12 given that term in section 340G–1(a)(2) of the Pub13 lic Health Service Act (42 U.S.C. 256g–1(a)(2)). 

14 (4) AUTHORIZATION OF APPROPRIATIONS.— 

15 There are authorized to be appropriated such sums 

16 as are necessary to carry out the demonstration pro17 gram under this subsection. 

18 Subtitle C—Advancing Health Eq19 uity Through Payment and De20 livery Reform 

21 SEC. 441. SENSE OF CONGRESS. 

22 It is the Sense of Congress that the sustainability of 

23 the U.S. health care system hinges on restructuring how 

24 health care is paid for, shifting away from paying for the 

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1 vide. High value care is care that provides higher quality 

2 care more efficiently, achieving greater health improve3 ment and better health outcomes at lower cost (per patient 

4 and overall). A high value health care system must deliver 

5 timely, accessible, well-coordinated, high quality, culturally 

6 centered, and language appropriate care to everyone. 

7 Therefore, eliminating health disparities and achieving 

8 health equity must be central to efforts to achieve a high 

9 value health care system. This will require tailored inter10 ventions and targeted investments to address inequities in 

11 health and health care to make sure that health care deliv12 ery and payment efforts are responsive to and inclusive 

13 of the needs of communities of color and other commu14 nities experiencing disparities. New models of value-based 

15 payment and care delivery should consider the holistic 

16 needs of the patient population, including social deter17 minants of health and behavioral health needs. 

18 SEC. 442. CENTERS FOR MEDICARE & MEDICAID SERVICES 

19 QUALITY PAYMENT PROGRAM. 

20 (a) IN GENERAL.—The Centers for Medicare & Med21 icaid Services Quality Payment Program, developed 

22 through implementation of the Medicare Access and CHIP 

23 Reauthorization Act of 2015, should explicitly integrate 

24 ‘‘achieving health equity’’ across all measures and activi25 ties, including the Merit-based Payment Incentive System 


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1 and Alternative Payment Models. In addition, CMS should 

2 identify limited-English proficient (LEP) persons as a spe3 cific underserved group within the program and give high 

4 weight to providing language services for non-English 

5 speakers. Clinicians can demonstrate performance in this 

6 category by developing language assistance plans, pro7 viding oral interpretation services, and providing trans8 lated documents for the population served or eligible to 

9 be served. 

10 (b) STRATIFIED DATA.—CMS should include an ex11 plicit reference that data stratification and reporting is 

12 one way of working to achieve health equity. CMS should 

13 require that in reporting this measure, clinicians should 

14 stratify clinical quality measures by disparity variables, in15 cluding race, ethnicity, preferred language, disability sta16 tus, sexual orientation, and gender identity, psychological 

17 and behavioral status. Clinicians can use existing demo18 graphic data collection fields in CEHRT to do this. Strati19 fied data can help clinicians identify and distinguish ef20 forts to improve quality from efforts to reduce disparities, 

21 which may not correlate without dedicated work. All par22 ticipating entities in the Quality Payment Program should 

23 adopt 2015 Certified Electronic Health Records Tech24 nology as a condition of participating in the program. 


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1 (c) QUALITY IMPROVEMENT ACTIVITIES.—Further, 

2 CMS, upon yearly review of the Quality Payment Pro3 gram, should add quality improvement activities that im4 plement the Culturally and Linguistically Accessible 

5 Standards (CLAS) standards as Improvement Activities. 

6 SEC. 443. DEVELOPMENT AND TESTING OF DISPARITY RE7 DUCING DELIVERY AND PAYMENT MODELS. 

8 (a) IN GENERAL.—The Center for Medicaid and 

9 Medicare Innovation (CMMI) will establish a dedicated 

10 fund to identify, pilot, evaluate and scale delivery and pay11 ment models that target health disparities among racial 

12 and ethnic minorities, including models that support high13 value non-medical services that address socially-deter14 mined barriers to health including: English proficiency, 

15 health literacy, case management, transportation and en16 rollment assistance which will help to reduce disparities 

17 and impact the overall cost of care. 

18 (b) PILOT PROGRAMS.—Pilot and demonstration pro19 grams that include partnerships with entities including 

20 community based organizations or other non-profit entities 

21 to help address socially determined barriers to health and 

22 health care will be given priority. 

23 (c) ALTERNATIVES.—Require all CMMI funded alter24 native delivery and payment models to include measures 

25 to assess and track their impact on health disparities, 


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1 using existing measures such as, but not limited to, the 

2 National Quality Forum Healthcare Disparities and Cul3 tural Competency Measures, and stratified by race, eth4 nicity, English proficiency, gender identity, sexual orienta5 tion, and disability status. 

6 SEC. 444. SUPPORTING SAFETY NET AND COMMUNITY7 BASED PROVIDERS TO COMPETE IN VALUE8 BASED PAYMENT SYSTEMS. 

9 (a) IN GENERAL.—All proposed pay for performance 

10 and alternative payment models, developed and tested by 

11 CMMI, or any other HHS agency should be assessed for 

12 potential impact on safety net, community based, and crit13 ical access providers, including federally qualified health 

14 centers. 

15 (b) NEW MODELS.—The rollout of new payment 

16 models should include training and additional up front re17 sources for community based and safety net providers to 

18 enable them to participate in them. 

19 Subtitle D—Health Empowerment 

20 Zones 

21 SEC. 451. SHORT TITLE. 

22 This subtitle may be cited as the ‘‘Health Empower23 ment Zone Act of 2018’’. 

24 SEC. 452. FINDINGS. 

25 The Congress finds the following: 


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1 (1) Numerous studies and reports, including 

2 the 2015 National Healthcare Disparities Report of 

3 the Administration on Healthcare Research and 

4 Quality and the 2002 Unequal Treatment Report of 

5 the Institute of Medicine, document the extensive6 ness to which health disparities exist across the 

7 country. 

8 (2) These studies have found that, on average, 

9 racial and ethnic minorities are disproportionately 

10 afflicted with chronic and acute conditions—such as 

11 cancer, diabetes, musculoskeletal disease, obesity, 

12 and hypertension—and suffer worse health out13 comes, worse health status, and higher mortality 

14 rates than their White counterparts. 

15 (3) Several recent studies also show that health 

16 disparities are a function of not only access to health 

17 care, but also the social determinants of health—in18 cluding the environment, the physical structure of 

19 communities, nutrition and food options, educational 

20 attainment and health literacy, employment, race, 

21 ethnicity, immigration status, geography, and lan22 guage preference—that directly and indirectly affect 

23 the health, health care, and wellness of individuals 

24 and communities. 


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1 (4) Integrally involving and fully supporting the 

2 communities most affected by health inequities in 

3 the assessment, planning, launch, and evaluation of 

4 health disparity elimination efforts are among the 

5 leading recommendations made to adequately ad6 dress and ultimately reduce health disparities. 

7 (5) Recommendations also include supporting 

8 the efforts of community stakeholders from a broad 

9 cross section—including, but not limited to local 

10 businesses, local departments of commerce, edu11 cation, labor, urban planning, and transportation, 

12 and community-based and other nonprofit organiza13 tions, including national and regional intermediaries 

14 with demonstrated capacity to serve low-income 

15 urban communities—to find areas of common 

16 ground around health disparity elimination and col17 laborate to improve the overall health and wellness 

18 of a community and its residents. 

19 SEC. 453. DESIGNATION OF HEALTH EMPOWERMENT 

20 ZONES. 

21 (a) IN GENERAL.—At the request of an eligible com22 munity partnership, the Secretary may designate an eligi23 ble area as a health empowerment zone. 

24 (b) ELIGIBILITY CRITERIA.— 


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1 (1) ELIGIBLE COMMUNITY PARTNERSHIP.—A 

2 community partnership is eligible to submit a re3 quest under this section if the partnership— 

4 (A) demonstrates widespread public sup5 port from key individuals and entities in the eli6 gible area, including members of the target 

7 community, State and local governments, non8 profit organizations including national and re9 gional intermediaries with demonstrated capac10 ity to serve low-income urban communities, and 

11 community and industry leaders, for designa12 tion of the eligible area as a health empower13 ment zone; and 

14 (B) includes representatives of— 

15 (i) a broad cross section of stake16 holders and residents from communities in 

17 the eligible area experiencing dispropor18 tionate disparities in health status and 

19 health care; and 

20 (ii) organizations, facilities, and insti21 tutions that have a history of working 

22 within and serving such communities. 

23 (2) ELIGIBLE AREA.—An area is eligible to be 

24 designated as a health empowerment zone under this 

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1 rience disproportionate disparities in health status 

2 and health care. In determining whether a commu3 nity experiences such disparities, the Secretary shall 

4 consider the data collected by the Department of 

5 Health and Human Services focusing on the fol6 lowing areas: 

7 (A) Access to affordable, high-quality 

8 health services. 

9 (B) The prevalence of disproportionate 

10 rates of certain illnesses or diseases including 

11 the following: 

12 (i) Arthritis, osteoporosis, chronic 

13 back conditions, and other musculoskeletal 

14 diseases. 

15 (ii) Cancer. 

16 (iii) Chronic kidney disease. 

17 (iv) Diabetes. 

18 (v) Injury (intentional and uninten19 tional). 

20 (vi) Violence (intimate and non21 intimate). 

22 (vii) Maternal and paternal illnesses 

23 and diseases. 

24 (viii) Infant mortality. 


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1 (ix) Mental illness and other disabil2 ities. 

3 (x) Substance abuse treatment and 

4 prevention, including underage drinking. 

5 (xi) Nutrition, obesity, and overweight 

6 conditions. 

7 (xii) Heart disease. 

8 (xiii) Hypertension. 

9 (xiv) Cerebrovascular disease or 

10 stroke. 

11 (xv) Tuberculosis. 

12 (xvi) HIV/AIDS and other sexually 

13 transmitted infections. 

14 (xvii) Viral hepatitis. 

15 (xviii) Asthma. 

16 (xix) Tooth decay and other oral 

17 health issues. 

18 (C) Within the target community, the his19 torical and persistent presence of conditions 

20 that have been found to contribute to health 

21 disparities including any such conditions re22 specting the following: 

23 (i) Poverty. 

24 (ii) Educational status and the quality 

25 of community schools. 


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1 (iii) Income. 

2 (iv) Access to high-quality affordable 

3 health care. 

4 (v) Work and work environment. 

5 (vi) Environmental conditions in the 

6 community, including with respect to clean 

7 water, clean air, and the presence or ab8 sence of pollutants. 

9 (vii) Language and English pro10 ficiency. 

11 (viii) Access to affordable healthy 

12 food. 

13 (ix) Access to ethnically and culturally 

14 diverse health and human service providers 

15 and practitioners. 

16 (x) Access to culturally and linguis17 tically competent health and human serv18 ices and health and human service pro19 viders. 

20 (xi) Health-supporting infrastructure. 

21 (xii) Health insurance that is ade22 quate and affordable. 

23 (xiii) Race, racism, and bigotry (con24 scious and unconscious). 

25 (xiv) Sexual orientation. 


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1 (xv) Health literacy. 

2 (xvi) Place of residence (such as 

3 urban areas, rural areas, and Tribal res4 ervations). 

5 (xvii) Stress. 

6 (c) PROCEDURE.— 

7 (1) REQUEST.—A request under subsection (a) 

8 shall— 

9 (A) describe the bounds of the area to be 

10 designated as a health empowerment zone and 

11 the process used to select those bounds; 

12 (B) demonstrate that the partnership sub13 mitting the request is an eligible community 

14 partnership described in subsection (b)(1); 

15 (C) demonstrate that the area is an eligible 

16 area described in subsection (b)(2); 

17 (D) include a comprehensive assessment of 

18 disparities in health status and health care ex19 perience by one or more communities in the 

20 area; 

21 (E) set forth— 

22 (i) a vision and a set of values for the 

23 area; and 

24 (ii) a comprehensive and holistic set of 

25 goals to be achieved in the area through 


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1 designation as a health empowerment zone; 

2 and 

3 (F) include a strategic plan and an action 

4 plan for achieving the goals described in sub5 paragraph (E)(ii). 

6 (2) APPROVAL.—Not later than 60 days after 

7 the receipt of a request for designation of an area 

8 as a health empowerment zone under this section, 

9 the Secretary shall approve or disapprove the re10 quest. 

11 (d) MINIMUM NUMBER.—The Secretary— 

12 (1) shall designate not more than 110 health 

13 empowerment zones under this section; and 

14 (2) shall designate at least one health empower15 ment zone in each of the several States, the District 

16 of Columbia, and each territory or possession of the 

17 United States. 

18 SEC. 454. ASSISTANCE TO THOSE SEEKING DESIGNATION. 

19 At the request of any organization or entity seeking 

20 to submit a request under section 453(a), the Secretary 

21 shall provide technical assistance, and may award a grant, 

22 to assist such organization or entity— 

23 (1) to form an eligible community partnership 

24 described in section 453(b)(1); 


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1 (2) to complete a health assessment, including 

2 an assessment of health disparities under section 

3 453(c)(1)(D); or 

4 (3) to prepare and submit a request, including 

5 a strategic plan, in accordance with section 453. 

6 SEC. 455. BENEFITS OF DESIGNATION. 

7 (a) PRIORITY.—In awarding any competitive grant, 

8 a Federal official shall give priority to any applicant 

9 that— 

10 (1) meets the eligibility criteria for the grant; 

11 (2) proposes to use the grant for activities in a 

12 health empowerment zone; and 

13 (3) demonstrates that such activities will di14 rectly and significantly further the goals of the stra15 tegic plan approved for such zone under section 453. 

16 (b) GRANTS FOR INITIAL IMPLEMENTATION OF

17 STRATEGIC PLAN.— 

18 (1) IN GENERAL.—Upon designating an eligible 

19 area as a health empowerment zone at the request 

20 of an eligible community partnership, the Secretary 

21 shall, subject to the availability of appropriations, 

22 make a grant to the community partnership for im23 plementation of the strategic plan for such zone. 

24 (2) GRANT PERIOD.—A grant under paragraph 

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1 riod of 2 years and may be renewed, except that the 

2 total period of grants under paragraph (1) for such 

3 zone may not exceed 10 years. 

4 (3) LIMITATION.—In awarding grants under 

5 this subsection, the Secretary shall not give less pri6 ority to an applicant or reduce the amount of a 

7 grant because the Secretary rendered technical as8 sistance or made a grant to the same applicant 

9 under section 454. 

10 (4) REPORTING.—The Secretary shall establish 

11 metrics for measuring the progress of grantees 

12 under this subsection and, based on such metrics, 

13 require each such grantee to report to the Secretary 

14 not less than every 6 months on the progress in im15 plementing the strategic plan for the health em16 powerment zone. 

17 SEC. 456. DEFINITION. 

18 In this subtitle, the term ‘‘Secretary’’ means the Sec19 retary of Health and Human Services, acting through the 

20 Administrator of the Health Resources and Services Ad21 ministration and the Deputy Assistant Secretary for Mi22 nority Health, and in cooperation with the Director of the 

23 Office of Community Services and the Director of the Na24 tional Institute for Minority Health and Health Dispari25 ties. 


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1 SEC. 457. AUTHORIZATION OF APPROPRIATIONS. 

2 To carry out this subtitle, there is authorized to be 

3 appropriated $100,000,000 for fiscal year 2019. 

4 Subtitle E—At-Risk Community 

5 Coverage 

6 SEC. 461. MEDICAID COVERAGE FOR CITIZENS OF FREELY 

7 ASSOCIATED STATES. 

8 (a) IN GENERAL.—Section 402(b)(2) of the Personal 

9 Responsibility and Work Opportunity Reconciliation Act 

10 of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at 

11 the end the following new subparagraph: 

12 ‘‘(G) MEDICAID EXCEPTION FOR CITIZENS

13 OF FREELY ASSOCIATED STATES.—With respect 

14 to eligibility for benefits for the designated Fed15 eral program defined in paragraph (3)(C) (re16 lating to the Medicaid program), section 401(a) 

17 and paragraph (1) shall not apply to any indi18 vidual who lawfully resides in 1 of the 50 States 

19 or the District of Columbia in accordance with 

20 the Compacts of Free Association between the 

21 Government of the United States and the Gov22 ernments of the Federated States of Micro23 nesia, the Republic of the Marshall Islands, and 

24 the Republic of Palau and shall not apply, at 

25 the option of the Governor of Puerto Rico, the 

26 Virgin Islands, Guam, the Northern Mariana 


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1 Islands, or American Samoa as communicated 

2 to the Secretary of Health and Human Services 

3 in writing, to any individual who lawfully re4 sides in the respective territory in accordance 

5 with such Compacts.’’. 

6 (b) EXCEPTION TO 5-YEAR LIMITED ELIGIBILITY.— 

7 Section 403(d) of such Act (8 U.S.C. 1613(d)) is amend8 ed— 

9 (1) in paragraph (1), by striking ‘‘or’’ at the 

10 end; 

11 (2) in paragraph (2), by striking the period at 

12 the end and inserting ‘‘; or’’; and 

13 (3) by adding at the end the following new 

14 paragraph: 

15 ‘‘(3) an individual described in section 

16 402(b)(2)(G), but only with respect to the des17 ignated Federal program defined in section 

18 402(b)(3)(C).’’. 

19 (c) DEFINITION OF QUALIFIED ALIEN.—Section 

20 431(b) of such Act (8 U.S.C. 1641(b)) is amended— 

21 (1) in paragraph (6), by striking ‘‘; or’’ at the 

22 end and inserting a comma; 

23 (2) in paragraph (7), by striking the period at 

24 the end and inserting ‘‘, or’’; and 


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1 (3) by adding at the end the following new 

2 paragraph: 

3 ‘‘(8) an individual who lawfully resides in the 

4 United States in accordance with a Compact of Free 

5 Association referred to in section 402(b)(2)(G), but 

6 only with respect to the designated Federal program 

7 defined in section 402(b)(3)(C) (relating to the Med8 icaid program).’’. 

9 (d) CONFORMING AMENDMENTS.—Section 1108 of 

10 the Social Security Act (42 U.S.C. 1308) is amended— 

11 (1) in subsection (f), in the matter preceding 

12 paragraph (1), by striking ‘‘subsection (g)’’ and in13 serting ‘‘subsections (g) and (h)’’; and 

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

15 ‘‘(h) Expenditures for medical assistance provided to 

16 an individual described in section 431(b)(8) of the Per17 sonal Responsibility and Work Opportunity Reconciliation 

18 Act of 1996 shall not be taken into account for purposes 

19 of applying payment limits under subsections (f) and 

20 (g).’’. 

21 (e) EFFECTIVE DATE.—The amendments made by 

22 this section shall apply to benefits for items and services 

23 furnished on or after the date of the enactment of this 

24 Act. 


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1 SEC. 462. AT-RISK YOUTH MEDICAID PROTECTION. 

2 (a) IN GENERAL.—Section 1902 of the Social Secu3 rity Act (42 U.S.C. 1396a) is amended— 

4 (1) in subsection (a)— 

5 (A) by striking ‘‘and’’ at the end of para6 graph (82); 

7 (B) by striking the period at the end of 

8 paragraph (83) and inserting ‘‘; and’’; and 

9 (C) by inserting after paragraph (83) the 

10 following new paragraph: 

11 ‘‘(84) provide that— 

12 ‘‘(A) the State shall not terminate eligi13 bility for medical assistance under a State plan 

14 for an individual who is an eligible juvenile (as 

15 defined in subsection (nn)(2)) because the juve16 nile is an inmate of a public institution (as de17 fined in subsection (nn)(3)), but may suspend 

18 coverage during the period the juvenile is such 

19 an inmate; 

20 ‘‘(B) the State shall restore coverage for 

21 such medical assistance to such an individual 

22 upon the individual’s release from any such 

23 public institution, without requiring a new ap24 plication from the individual, unless (and until 

25 such date as) there is a determination that the 


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1 individual no longer meets the eligibility re2 quirements for such medical assistance; and 

3 ‘‘(C) the State shall process any applica4 tion for medical assistance submitted by, or on 

5 behalf of, a juvenile who is an inmate of a pub6 lic institution notwithstanding that the juvenile 

7 is such an inmate.’’; and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(nn) JUVENILE; ELIGIBLE JUVENILE; PUBLIC IN11 STITUTION.—For purposes of subsection (a)(84) and this 

12 subsection: 

13 ‘‘(1) JUVENILE.—The term ‘juvenile’ means an 

14 individual who is— 

15 ‘‘(A) under 21 years of age; or 

16 ‘‘(B) is described in subsection 

17 (a)(10)(A)(i)(IX). 

18 ‘‘(2) ELIGIBLE JUVENILE.—The term ‘eligible 

19 juvenile’ means a juvenile who is an inmate of a 

20 public institution and was eligible for medical assist21 ance under the State plan immediately before be22 coming an inmate of such a public institution or who 

23 becomes eligible for such medical assistance while an 

24 inmate of a public institution. 


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1 ‘‘(3) INMATE OF A PUBLIC INSTITUTION.—The 

2 term ‘inmate of a public institution’ has the meaning 

3 given such term for purposes of applying the sub4 division (A) following paragraph (29) of section 

5 1905(a), taking into account the exception in such 

6 subdivision for a patient of a medical institution.’’. 

7 (b) NO CHANGE IN EXCLUSION FROM MEDICAL AS8 SISTANCE FOR INMATES OF PUBLIC INSTITUTIONS.— 

9 Nothing in this section shall be construed as changing the 

10 exclusion from medical assistance under the subdivision 

11 (A) following paragraph (29) of section 1905(a) of the So12 cial Security Act (42 U.S.C. 1396d(a)), including any ap13 plicable restrictions on a State submitting claims for Fed14 eral financial participation under title XIX of such Act 

15 for such assistance. 

16 (c) NO CHANGE IN CONTINUITY OF ELIGIBILITY BE17 FORE ADJUDICATION OR SENTENCING.—Nothing in this 

18 section shall be construed to mandate, encourage, or sug19 gest that a State suspend or terminate coverage for indi20 viduals before they have been adjudicated or sentenced. 

21 (d) EFFECTIVE DATE.— 

22 (1) IN GENERAL.—Except as provided in para23 graph (2), the amendments made by subsection (a) 

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1 mates of public institutions on or after the date that 

2 is 1 year after the date of the enactment of this Act. 

3 (2) RULE FOR CHANGES REQUIRING STATE

4 LEGISLATION.—In the case of a State plan for med5 ical assistance under title XIX of the Social Security 

6 Act which the Secretary of Health and Human Serv7 ices determines requires State legislation (other than 

8 legislation appropriating funds) in order for the plan 

9 to meet the additional requirements imposed by the 

10 amendments made by subsection (a), the State plan 

11 shall not be regarded as failing to comply with the 

12 requirements of such title solely on the basis of its 

13 failure to meet these additional requirements before 

14 the first day of the first calendar quarter beginning 

15 after the close of the first regular session of the 

16 State legislature that begins after the date of the en17 actment of this Act. For purposes of the previous 

18 sentence, in the case of a State that has a 2-year 

19 legislative session, each year of such session shall be 

20 deemed to be a separate regular session of the State 

21 legislature. 


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1 TITLE V—IMPROVING HEALTH 

2 OUTCOMES FOR WOMEN, 

3 CHILDREN, AND FAMILIES 

4 Subtitle A—In General 

5 SEC. 501. GRANTS TO PROMOTE HEALTH FOR UNDER6 SERVED COMMUNITIES. 

7 Part Q of title III of the Public Health Service Act 

8 (42 U.S.C. 280g et seq.) is amended by adding at the end 

9 the following: 

10 ‘‘SEC. 399Z–3. GRANTS TO PROMOTE HEALTH FOR UNDER11 SERVED COMMUNITIES. 

12 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, in col13 laboration with the Administrator of the Health Resources 

14 and Services Administration and other Federal officials 

15 determined appropriate by the Secretary, is authorized to 

16 award grants to eligible entities— 

17 ‘‘(1) to promote health for underserved commu18 nities, with preference given to projects that benefit 

19 racial and ethnic minority women, racial and ethnic 

20 minority children, adolescents, and lesbian, gay, bi21 sexual, transgender, queer, or questioning commu22 nities; and 

23 ‘‘(2) to strengthen health outreach initiatives in 

24 medically underserved communities, including lin25 guistically isolated populations. 


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1 ‘‘(b) USE OF FUNDS.—Grants awarded pursuant to 

2 subsection (a) may be used to support the activities of 

3 community health workers, including such activities— 

4 ‘‘(1) to educate and provide outreach regarding 

5 enrollment in health insurance including the State 

6 Children’s Health Insurance Program under title 

7 XXI of the Social Security Act, Medicare under title 

8 XVIII of such Act, and Medicaid under title XIX of 

9 such Act; 

10 ‘‘(2) to educate and provide outreach in a com11 munity setting regarding health problems prevalent 

12 among underserved communities, and especially 

13 among racial and ethnic minority women, racial and 

14 ethnic minority children, adolescents, and lesbian, 

15 gay, bisexual, transgender, queer, or questioning 

16 communities; 

17 ‘‘(3) to educate and provide experiential learn18 ing opportunities and target risk factors and healthy 

19 behaviors that impede or contribute to achieving 

20 positive health outcomes, including— 

21 ‘‘(A) healthy nutrition; 

22 ‘‘(B) physical activity; 

23 ‘‘(C) overweight or obesity; 

24 ‘‘(D) tobacco use; 

25 ‘‘(E) alcohol and substance use; 


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1 ‘‘(F) injury and violence; 

2 ‘‘(G) sexual health; 

3 ‘‘(H) mental health; 

4 ‘‘(I) musculoskeletal health and arthritis; 

5 ‘‘(J) dental and oral health; 

6 ‘‘(K) understanding informed consent; and 

7 ‘‘(L) stigma; 

8 ‘‘(4) to promote community wellness and aware9 ness; and 

10 ‘‘(5) to educate and refer target populations to 

11 appropriate health care agencies and community12 based programs and organizations in order to in13 crease access to quality health care services, includ14 ing preventive health services. 

15 ‘‘(c) APPLICATION.— 

16 ‘‘(1) IN GENERAL.—Each eligible entity that 

17 desires to receive a grant under subsection (a) shall 

18 submit an application to the Secretary, at such time, 

19 in such manner, and accompanied by such additional 

20 information as the Secretary may require. 

21 ‘‘(2) CONTENTS.—Each application submitted 

22 pursuant to paragraph (1) shall— 

23 ‘‘(A) describe the activities for which as24 sistance under this section is sought; 


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1 ‘‘(B) contain an assurance that, with re2 spect to each community health worker pro3 gram receiving funds under the grant awarded, 

4 such program provides in-language training and 

5 supervision to community health workers to en6 able such workers to provide authorized pro7 gram activities in (at least) the most commonly 

8 used languages within a particular geographic 

9 region; 

10 ‘‘(C) contain an assurance that the appli11 cant will evaluate the effectiveness of commu12 nity health worker programs receiving funds 

13 under the grant; 

14 ‘‘(D) contain an assurance that each com15 munity health worker program receiving funds 

16 under the grant will provide culturally com17 petent services in the linguistic context most 

18 appropriate for the individuals served by the 

19 program; 

20 ‘‘(E) contain a plan to document and dis21 seminate project descriptions and results to 

22 other States and organizations as identified by 

23 the Secretary; and 

24 ‘‘(F) describe plans to enhance the capac25 ity of individuals to utilize health services and 


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1 health-related social services under Federal, 

2 State, and local programs by— 

3 ‘‘(i) assisting individuals in estab4 lishing eligibility under the programs and 

5 in receiving the services or other benefits 

6 of the programs; and 

7 ‘‘(ii) providing other services, as the 

8 Secretary determines to be appropriate, 

9 which may include transportation and 

10 translation services. 

11 ‘‘(d) PRIORITY.—In awarding grants under sub12 section (a), the Secretary shall give priority to those appli13 cants— 

14 ‘‘(1) who propose to target geographic areas 

15 that— 

16 ‘‘(A)(i) have a high percentage of residents 

17 who are uninsured or underinsured (if the tar18 geted geographic area is located in a State that 

19 has elected to make medical assistance available 

20 under section 1902(a)(10)(A)(i)(VIII) of the 

21 Social Security Act to individuals described in 

22 such section); 

23 ‘‘(ii) have a high percentage of under24 insured residents in a particular geographic 


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1 area (if the targeted geographic area is located 

2 in a State that has not so elected); or 

3 ‘‘(iii) have a high number of households ex4 periencing extreme poverty; and 

5 ‘‘(B) have a high percentage of families for 

6 whom English is not their primary language or 

7 including smaller limited-English-proficient 

8 communities within the region that are not oth9 erwise reached by linguistically appropriate 

10 health services; 

11 ‘‘(2) with experience in providing health or 

12 health-related social services to individuals who are 

13 underserved with respect to such services; and 

14 ‘‘(3) with documented community activity and 

15 experience with community health workers. 

16 ‘‘(e) COLLABORATION WITH ACADEMIC INSTITU17 TIONS.—The Secretary shall encourage community health 

18 worker programs receiving funds under this section to col19 laborate with academic institutions, including minority20 serving institutions. Nothing in this section shall be con21 strued to require such collaboration. 

22 ‘‘(f) QUALITY ASSURANCE AND COST EFFECTIVE23 NESS.—The Secretary shall establish guidelines for ensur24 ing the quality of the training and supervision of commu25 nity health workers under the programs funded under this 


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1 section and for ensuring the cost effectiveness of such pro2 grams. 

3 ‘‘(g) MONITORING.—The Secretary shall monitor 

4 community health worker programs identified in approved 

5 applications and shall determine whether such programs 

6 are in compliance with the guidelines established under 

7 subsection (f). 

8 ‘‘(h) TECHNICAL ASSISTANCE.—The Secretary may 

9 provide technical assistance to community health worker 

10 programs identified in approved applications with respect 

11 to planning, developing, and operating programs under the 

12 grant. 

13 ‘‘(i) REPORT TO CONGRESS.— 

14 ‘‘(1) IN GENERAL.—Not later than 4 years 

15 after the date on which the Secretary first awards 

16 grants under subsection (a), the Secretary shall sub17 mit to Congress a report regarding the grant 

18 project. 

19 ‘‘(2) CONTENTS.—The report required under 

20 paragraph (1) shall include the following: 

21 ‘‘(A) A description of the programs for 

22 which grant funds were used. 

23 ‘‘(B) The number of individuals served. 

24 ‘‘(C) An evaluation of— 


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1 ‘‘(i) the effectiveness of these pro2 grams; 

3 ‘‘(ii) the cost of these programs; and 

4 ‘‘(iii) the impact of the project on the 

5 health outcomes of the community resi6 dents. 

7 ‘‘(D) Recommendations for sustaining the 

8 community health worker programs developed 

9 or assisted under this section. 

10 ‘‘(E) Recommendations regarding training 

11 to enhance career opportunities for community 

12 health workers. 

13 ‘‘(j) DEFINITIONS.—In this section: 

14 ‘‘(1) COMMUNITY HEALTH WORKER.—The term 

15 ‘community health worker’ means an individual who 

16 promotes health or nutrition within the community 

17 in which the individual resides— 

18 ‘‘(A) by serving as a liaison between com19 munities and health care agencies; 

20 ‘‘(B) by providing guidance and social as21 sistance to community residents; 

22 ‘‘(C) by enhancing community residents’ 

23 ability to effectively communicate with health 

24 care providers; 


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1 ‘‘(D) by providing culturally and linguis2 tically appropriate health or nutrition edu3 cation; 

4 ‘‘(E) by advocating for individual and com5 munity health, including dental, oral, mental, 

6 and environmental health, or nutrition needs; 

7 ‘‘(F) by taking into consideration the 

8 needs of the communities served, including the 

9 prevalence rates of risk factors that impede 

10 achieving positive healthy outcomes among 

11 women and children, especially among racial 

12 and ethnic minority women and children; and 

13 ‘‘(G) by providing referral and followup 

14 services. 

15 ‘‘(2) COMMUNITY SETTING.—The term ‘commu16 nity setting’ means a home or a community organi17 zation that serves a population. 

18 ‘‘(3) ELIGIBLE ENTITY.—The term ‘eligible en19 tity’ means— 

20 ‘‘(A) a unit of State, territorial, local, or 

21 Tribal government (including a federally recog22 nized Tribe or Alaska Native village); or 

23 ‘‘(B) a community-based organization. 


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1 ‘‘(4) MEDICALLY UNDERSERVED COMMUNITY.— 

2 The term ‘medically underserved community’ means 

3 a community— 

4 ‘‘(A) that has a substantial number of in5 dividuals who are members of a medically un6 derserved population, as defined by section 

7 330(b)(3); 

8 ‘‘(B) a significant portion of which is a 

9 health professional shortage area as designated 

10 under section 332; and 

11 ‘‘(C) that includes populations that are lin12 guistically isolated, such as geographic areas 

13 with a shortage of health professionals able to 

14 provide linguistically appropriate services. 

15 ‘‘(5) SUPPORT.—The term ‘support’ means the 

16 provision of training, supervision, and materials 

17 needed to effectively deliver the services described in 

18 subsection (b), reimbursement for services, and 

19 other benefits. 

20 ‘‘(6) TARGET POPULATION.—The term ‘target 

21 population means’ women of reproductive age, per22 sons who identify as lesbian, gay, bisexual, 

23 transgender, and/or queer, and people under age 25. 


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1 ‘‘(k) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated to carry out this section 

3 $15,000,000 for each of fiscal years 2019 through 2023.’’. 

4 SEC. 502. REMOVING BARRIERS TO HEALTH CARE AND NU5 TRITION ASSISTANCE FOR CHILDREN, PREG6 NANT PERSONS, AND LAWFULLY PRESENT IN7 DIVIDUALS. 

8 (a) MEDICAID.—Section 1903(v) of the Social Secu9 rity Act (42 U.S.C. 1396b(v)) is amended by striking 

10 paragraph (4) and inserting the following new paragraph: 

11 ‘‘(4)(A) Notwithstanding sections 401(a), 402(b), 

12 403, and 421 of the Personal Responsibility and Work Op13 portunity Reconciliation Act of 1996 and paragraph (1), 

14 payment shall be made to a State under this section for 

15 medical assistance furnished to an alien under this title 

16 (including an alien described in such paragraph) who 

17 meets any of the following conditions: 

18 ‘‘(i) The alien is otherwise eligible for such as19 sistance under the State plan approved under this 

20 title (other than the requirement of the receipt of 

21 aid or assistance under title IV, supplemental secu22 rity income benefits under title XVI, or a State sup23 plementary payment) within either or both of the 

24 following eligibility categories: 


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1 ‘‘(I) Children under 21 years of age, in2 cluding any optional targeted low-income child 

3 (as such term is defined in section 

4 1905(u)(2)(B)). 

5 ‘‘(II) Pregnant persons during pregnancy 

6 and during the 60-day period beginning on the 

7 last day of the pregnancy. 

8 ‘‘(ii) The alien is lawfully present in the United 

9 States. 

10 ‘‘(B) No debt shall accrue under an affidavit of sup11 port against any sponsor of an alien who meets the condi12 tions specified in subparagraph (A) on the basis of the 

13 provision of medical assistance to such alien under this 

14 paragraph and the cost of such assistance shall not be con15 sidered as an unreimbursed cost.’’. 

16 (b) SCHIP.—Subparagraph (J) of section 

17 2107(e)(1) of the Social Security Act (42 U.S.C. 

18 1397gg(e)(1)) is amended to read as follows: 

19 ‘‘(J) Paragraph (4) of section 1903(v) (re20 lating to coverage of categories of children, 

21 pregnant persons, and other lawfully present in22 dividuals).’’. 

23 (c) SUPPLEMENTAL NUTRITION ASSISTANCE.—Not24 withstanding sections 401(a), 402(a), and 403(a) of the 

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1 ation Act of 1996 (8 U.S.C. 1611(a); 1612(a); 1613(a)) 

2 and section 6(f) of the Food and Nutrition Act of 2008 

3 (7 U.S.C. 2015(f)), persons who are lawfully present in 

4 the United States shall be not be ineligible for benefits 

5 under the supplemental nutrition assistance program on 

6 the basis of their immigration status or date of entry into 

7 the United States. 

8 (d) ELIGIBILITY FOR FAMILIES WITH CHILDREN.— 

9 Section 421(d)(3) of the Personal Responsibility and 

10 Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 

11 1631(d)(3)) is amended by striking ‘‘to the extent that 

12 a qualified alien is eligible under section 402(a)(2)(J)’’ 

13 and inserting, ‘‘to the extent that a child is a member of 

14 a household under the supplemental nutrition assistance 

15 program’’. 

16 (e) ENSURING PROPER SCREENING.—Section 

17 11(e)(2)(B) of the Food and Nutrition Act of 2008 (7 

18 U.S.C. 2020(e)(2)(B)) is amended— 

19 (1) by redesignating clauses (vi) and (vii) as 

20 clauses (vii) and (viii); and 

21 (2) by inserting after clause (v) the following: 

22 ‘‘(vi) shall provide a method for imple23 menting section 421 of the Personal Re24 sponsibility and Work Opportunity Rec25 onciliation Act of 1996 (8 U.S.C. 1631) 


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1 that does not require any unnecessary in2 formation from persons who may be ex3 empt from that provision;’’. 

4 SEC. 503. REPEAL OF DENIAL OF BENEFITS. 

5 Section 115 of the Personal Responsibility and Work 

6 Opportunity Reconciliation Act of 1996 (21 U.S.C. 862a) 

7 is amended— 

8 (1) in subsection (a), by striking paragraph (2); 

9 (2) in subsection (b), by striking paragraph (2); 

10 and 

11 (3) in subsection (e), by striking paragraph (2). 

12 SEC. 504. BIRTH DEFECTS PREVENTION, RISK REDUCTION, 

13 AND AWARENESS. 

14 (a) IN GENERAL.—The Secretary shall establish and 

15 implement a birth defects prevention and public awareness 

16 program, consisting of the activities described in sub17 sections (c) and (d). 

18 (b) DEFINITIONS.—In this section: 

19 (1) The term ‘‘maternal’’ refers to persons who 

20 are pregnant or breastfeeding of all gender identi21 ties. 

22 (2) The term ‘‘pregnancy and breastfeeding in23 formation services’’ includes only— 

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1 garding maternal exposures during pregnancy 

2 that may be associated with birth defects or 

3 other health risks, such as exposures to medica4 tions, chemicals, infections, foodborne patho5 gens, illnesses, nutrition, or lifestyle factors; 

6 (B) information services to provide accu7 rate, evidence-based, clinical information re8 garding maternal exposures during breast9 feeding that may be associated with health risks 

10 to a breast-fed infant, such as exposures to 

11 medications, chemicals, infections, foodborne 

12 pathogens, illnesses, nutrition, or lifestyle fac13 tors; 

14 (C) the provision of accurate, evidence15 based information weighing risks of exposures 

16 during breastfeeding against the benefits of 

17 breastfeeding; and 

18 (D) the provision of information described 

19 in subparagraph (A), (B), or (C) through coun20 selors, Web sites, fact sheets, telephonic or elec21 tronic communication, community outreach ef22 forts, or other appropriate means. 

23 (3) The term ‘‘Secretary’’ means the Secretary 

24 of Health and Human Services, acting through the 


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1 Director of the Centers for Disease Control and Pre2 vention. 

3 (c) NATIONWIDE MEDIA CAMPAIGN.—In carrying out 

4 subsection (a), the Secretary shall conduct or support a 

5 nationwide media campaign to increase awareness among 

6 health care providers and at-risk populations about preg7 nancy and breastfeeding information services. 

8 (d) GRANTS FOR PREGNANCY AND BREASTFEEDING

9 INFORMATION SERVICES.— 

10 (1) IN GENERAL.—In carrying out subsection 

11 (a), the Secretary shall award grants to State or re12 gional agencies or organizations for any of the fol13 lowing: 

14 (A) INFORMATION SERVICES.—The provi15 sion of, or campaigns to increase awareness 

16 about, pregnancy and breastfeeding information 

17 services. 

18 (B) SURVEILLANCE AND RESEARCH.—The 

19 conduct or support of— 

20 (i) surveillance of or research on— 

21 (I) maternal exposures and ma22 ternal health conditions that may in23 fluence the risk of birth defects, pre24 maturity, or other adverse pregnancy 

25 outcomes; and 


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1 (II) maternal exposures that may 

2 influence health risks to a breastfed 

3 infant; or 

4 (ii) networking to facilitate surveil5 lance or research described in this sub6 paragraph. 

7 (2) PREFERENCE FOR CERTAIN STATES.—The 

8 Secretary, in making any grant under this sub9 section, shall give preference to States, otherwise 

10 equally qualified, that have a pregnancy and 

11 breastfeeding information service in place. 

12 (3) MATCHING FUNDS.—The Secretary may 

13 only award a grant under this subsection to a State 

14 or regional agency or organization that agrees, with 

15 respect to the costs to be incurred in carrying out 

16 the grant activities, to make available (directly or 

17 through donations from public or private entities) 

18 non-Federal funds toward such costs in an amount 

19 equal to not less than 25 percent of the amount of 

20 the grant. 

21 (4) COORDINATION.—The Secretary shall en22 sure that activities funded through a grant under 

23 this subsection are coordinated, to the maximum ex24 tent practicable, with other birth defects prevention 

25 and environmental health activities of the Federal 


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1 Government, including with respect to pediatric envi2 ronmental health specialty units and children’s envi3 ronmental health centers. 

4 (e) EVALUATION.—In furtherance of the program 

5 under subsection (a), the Secretary shall provide for an 

6 evaluation of pregnancy and breastfeeding information 

7 services to identify efficient and effective models of— 

8 (1) providing information; 

9 (2) raising awareness and increasing knowledge 

10 about birth defects prevention measures and tar11 geting education to at-risk groups; 

12 (3) modifying risk behaviors; or 

13 (4) other outcome measures as determined ap14 propriate by the Secretary. 

15 (f) AUTHORIZATION OF APPROPRIATIONS.—To carry 

16 out this section, there are authorized to be appropriated 

17 $5,000,000 for fiscal year 2019, $6,000,000 for fiscal year 

18 2020, $7,000,000 for fiscal year 2021, $8,000,000 for fis19 cal year 2022, and $9,000,000 for fiscal year 2023. 

20 SEC. 505. PREVENTING MATERNAL DEATHS. 

21 (a) PROGRAM AUTHORIZED.— 

22 (1) IN GENERAL.—The Secretary of Health and 

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1 lish a grant program under which the Secretary may 

2 make grants to States for the purpose of— 

3 (A) carrying out the activities described in 

4 subsection (b)(1); 

5 (B) establishing and sustaining a State 

6 maternal mortality review committee, in accord7 ance with subsection (b)(2); 

8 (C) ensuring that the State department of 

9 health carries out the activities described in 

10 subsection (b)(3); 

11 (D) disseminating the case abstraction 

12 form developed under subsection (c); and 

13 (E) providing for the public disclosure of 

14 information, in accordance with subsection (d). 

15 (2) CRITERIA.—The Secretary shall establish 

16 criteria for determining eligibility for, and the 

17 amount of a grant awarded to, a State under para18 graph (1). Such criteria shall provide that in the 

19 case of a State that receives a grant under para20 graph (1) for a fiscal year and is determined by the 

21 Secretary to have not used such grant in accordance 

22 with this section, such State may not be eligible for 

23 such a grant for any subsequent fiscal year. 

24 (b) USE OF FUNDS.— 


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1 (1) REVIEW OF PREGNANCY-RELATED AND

2 PREGNANCY-ASSOCIATED DEATHS.—With respect to 

3 a State that receives a grant under subsection 

4 (a)(1), the following shall apply: 

5 (A) PROCESS FOR MANDATORY REPORTING

6 OF PREGNANCY-RELATED AND PREGNANCY-AS7 SOCIATED DEATHS.— 

8 (i) IN GENERAL.—The State, through 

9 the State maternal mortality review com10 mittee established under subsection (a)(1), 

11 shall develop a process that provides for 

12 mandatory and confidential case reporting 

13 to the State department of health by indi14 viduals and entities described in clause (ii) 

15 with respect to pregnancy-related and 

16 pregnancy-associated deaths. 

17 (ii) INDIVIDUALS AND ENTITIES DE18 SCRIBED.—Individuals and entities de19 scribed in this clause include each of the 

20 following: 

21 (I) Health care professionals. 

22 (II) Medical examiners. 

23 (III) Medical coroners. 

24 (IV) Hospitals. 

25 (V) Birth centers. 


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1 (VI) Other health care facilities. 

2 (VII) Other individuals respon3 sible for completing death records. 

4 (VIII) Other appropriate individ5 uals or entities specified by the Sec6 retary. 

7 (B) PROCESS FOR VOLUNTARY REPORTING

8 OF PREGNANCY-RELATED AND PREGNANCY-AS9 SOCIATED DEATHS.—The State, through the 

10 State maternal mortality review committee es11 tablished under subsection (a)(1), shall develop 

12 a process that provides for voluntary and con13 fidential case reporting to the State department 

14 of health by family members of the deceased 

15 and other individuals on possible pregnancy-re16 lated and pregnancy-associated deaths. Such 

17 process shall include— 

18 (i) making publicly available on the 

19 website of the State department of health 

20 a telephone number, Internet web link, and 

21 email address for such reporting; and 

22 (ii) publicizing to local professional or23 ganizations, community organizations, and 

24 social services agencies the availability of 

25 the telephone number, Internet web link, 


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1 and email address made available under 

2 clause (i). 

3 (C) IDENTIFICATION OF PREGNANCY-RE4 LATED AND PREGNANCY-ASSOCIATED DEATHS

5 BY STATE VITAL STATISTICS UNIT.—The State, 

6 through the vital statistics unit of the State, 

7 shall annually identify pregnancy-related and 

8 pregnancy-associated deaths occurring in such 

9 State in the year involved by— 

10 (i) matching each death record of a 

11 person in such year to a live birth certifi12 cate or an infant death record for the pur13 pose of identifying deaths of persons that 

14 occurred during pregnancy and within one 

15 year after the end of a pregnancy; 

16 (ii) identifying each death of a person 

17 reported during such year as having an un18 derlying or contributing cause of death re19 lated to pregnancy, regardless of the time 

20 that has passed between the end of the 

21 pregnancy and the death; 

22 (iii) collecting data from medical ex23 aminer and coroner reports; and 

24 (iv) using any other method the State 

25 may devise to identify maternal deaths 


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1 such as reviewing a random sample of re2 ported deaths of persons who could have 

3 been pregnant to ascertain cases of preg4 nancy-related and pregnancy-associated 

5 deaths that are not discernable from a re6 view of death records alone. 

7 For purposes of effectively collecting and ob8 taining data on pregnancy-related and preg9 nancy-associated deaths, the State shall adopt 

10 the most recent standardized birth and death 

11 records, as issued by the National Center for 

12 Vital Health Statistics, including the rec13 ommended checkbox section for pregnancy on 

14 each death record. 

15 (D) CASE INVESTIGATION AND DEVELOP16 MENT OF CASE SUMMARIES.— 

17 (i) IN GENERAL.—Following the re18 ceipt of reports by the State department of 

19 health pursuant to subparagraph (A) or 

20 (B) and the collection of cases of preg21 nancy-related and pregnancy-associated 

22 deaths by the vital statistics unit of the 

23 State under subparagraph (C), the State, 

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1 section (a)(1), shall investigate each case, 

2 using the case abstraction form described 

3 in subsection (c), and prepare a de-identi4 fied case summary for each case, which 

5 shall be reviewed by the committee and in6 cluded in applicable reports. The State de7 partment of health or vital statistics unit 

8 of the State, as the case may be, shall pro9 vide the State maternal mortality review 

10 committee with access to the information 

11 collected pursuant to subparagraph (A) or 

12 (B), or under subparagraph (C), as nec13 essary to carry out this subparagraph. 

14 (ii) MANDATORY DATA AND INFORMA15 TION.—Each case investigation under this 

16 subparagraph shall, subject to availability, 

17 include data and information obtained 

18 through— 

19 (I) medical examiner and autopsy 

20 reports of the person involved; 

21 (II) medical records of the per22 son, including such records related to 

23 health care prior to pregnancy, pre24 natal and postnatal care, labor and 

25 delivery care, emergency room care, 


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1 hospital discharge records, and any 

2 care delivered up until the time of 

3 death of the person; 

4 (III) oral and written interviews 

5 of individuals directly involved in the 

6 maternal care of the person during 

7 and immediately following the preg8 nancy of the person, including health 

9 care, mental health, and social service 

10 providers, as applicable; 

11 (IV) socioeconomic and other rel12 evant background information about 

13 the person; 

14 (V) any information collected 

15 under subparagraph (C)(i); and 

16 (VI) any other information on 

17 the cause of death of the person, such 

18 as social services and child welfare re19 ports. 

20 (iii) DISCRETIONARY DATA AND IN21 FORMATION.—Each case investigation 

22 under this subparagraph may include data 

23 and information obtained through oral or 

24 written interviews of the family of the per25 son. 


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1 (2) STATE MATERNAL MORTALITY REVIEW

2 COMMITTEES.— 

3 (A) MANDATORY ACTIVITIES.—A State 

4 maternal mortality review committee established 

5 under subsection (a)(1) shall carry out the fol6 lowing activities: 

7 (i) Develop the processes described in 

8 subparagraphs (A) and (B) of paragraph 

9 (1). 

10 (ii) Review the data and information 

11 collected by the vital statistics unit of the 

12 State under paragraph (1)(C) regarding 

13 pregnancy-related and pregnancy-associ14 ated deaths to identify trends, patterns, 

15 and disparities in adverse outcomes and 

16 address medical, non-medical, and system17 related factors that may have contributed 

18 to such pregnancy-related and pregnancy19 associated deaths and disparities. 

20 (iii) Carry out the activities described 

21 in paragraph (1)(D). 

22 (iv) Develop recommendations, based 

23 on the case summaries prepared under 

24 paragraph (1)(D) and the data and infor25 mation collected under paragraph (1)(C), 


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1 to improve maternal care, social and health 

2 services, and public health policy and insti3 tutions, including improving access to ma4 ternal care and social and health services 

5 and identifying disparities in maternal care 

6 and outcomes. 

7 (B) DISCRETIONARY ACTIVITIES.— 

8 (i) IN GENERAL.—A State maternal 

9 mortality review committee established 

10 under subsection (a)(1) may, while subject 

11 to confidentiality requirements, present 

12 findings and recommendations based on 

13 the case summaries prepared under para14 graph (1)(D) directly to a health care facil15 ity or its local or State professional organi16 zation for the purpose of— 

17 (I) instituting policy changes, 

18 educational activities, and improve19 ments in the quality of care provided 

20 by the facility; and 

21 (II) exploring and forming re22 gional collaborations. 

23 (ii) INVESTIGATION OF CASES OF SE24 VERE MATERNAL MORBIDITY.—A State 

25 maternal mortality review committee may 


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1 investigate cases of severe maternal mor2 bidity and any such investigation may in3 clude data and information obtained 

4 through— 

5 (I) identified patient registries; 

6 or 

7 (II) oral or written interviews of 

8 the person concerned and the family 

9 of such person. 

10 (C) COMPOSITION OF STATE MATERNAL

11 MORTALITY REVIEW COMMITTEES.— 

12 (i) IN GENERAL.—A State maternal 

13 mortality review committee established 

14 under subsection (a)(1) shall be multidisci15 plinary and diverse. Membership on the 

16 State maternal mortality review committee 

17 shall be reviewed annually by the State de18 partment of health to ensure that member19 ship representation requirements are being 

20 fulfilled in accordance with this subpara21 graph. 

22 (ii) REQUIRED MEMBERSHIP.—Each 

23 State maternal mortality review committee 

24 shall include— 


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1 (I) representatives from medical 

2 specialties providing care to pregnant 

3 and postpartum patients, including 

4 obstetricians (including generalists 

5 and maternal fetal medicine special6 ists) and family practice physicians; 

7 (II) certified nurse midwives, cer8 tified midwives, and advanced practice 

9 nurses; 

10 (III) hospital-based registered 

11 nurses; 

12 (IV) representatives of the ma13 ternal and child health department of 

14 the State department of health; 

15 (V) social service providers or so16 cial workers, including those with ex17 perience working with communities di18 verse with respect to race, ethnicity, 

19 and limited-English proficiency; 

20 (VI) chief medical examiners or 

21 designees; 

22 (VII) facility representatives, 

23 such as from hospitals or birth cen24 ters; 


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1 (VIII) patient advocates, commu2 nity maternal health organizations, 

3 and minority advocacy groups that 

4 represent those diverse racial and eth5 nic communities within the State that 

6 are the most affected by pregnancy7 related or pregnancy-associated deaths 

8 and by a lack of access to maternal 

9 health care services; and 

10 (IX) representatives of the de11 partments of health or public health 

12 of major cities in the State. 

13 (iii) DISCRETIONARY MEMBERSHIP.— 

14 Each State maternal mortality review com15 mittee may also include representatives 

16 from other relevant academic, health, so17 cial service, or policy professions or com18 munity organizations on an ongoing basis, 

19 or as needed, as determined beneficial by 

20 the committee, including— 

21 (I) anesthesiologists; 

22 (II) emergency physicians; 

23 (III) pathologists; 

24 (IV) epidemiologists; 

25 (V) intensivists; 


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1 (VI) nutritionists; 

2 (VII) mental health professionals; 

3 (VIII) substance use disorder 

4 treatment specialists; 

5 (IX) representatives of relevant 

6 patient and provider advocacy groups; 

7 (X) academics; 

8 (XI) paramedics; and 

9 (XII) risk management special10 ists. 

11 (iv) STAFF.—Staff of each State ma12 ternal mortality review committee shall in13 clude— 

14 (I) vital health statisticians, ma15 ternal child health statisticians, or 

16 epidemiologists; 

17 (II) a coordinator of the State 

18 maternal mortality review committee, 

19 to be designated by the State; and 

20 (III) administrative staff. 

21 (D) OPTION FOR STATES TO ESTABLISH

22 REGIONAL MATERNAL MORTALITY REVIEW COM23 MITTEES.—States may choose to partner with 

24 one or more neighboring States to carry out the 

25 activities required of a State maternal mortality 


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1 review committee under this section. In such a 

2 case, with respect to the States in such a part3 nership, any requirement under this section re4 lating to the reporting of information related to 

5 such activities shall be deemed to be fulfilled by 

6 each such State if a single such report is sub7 mitted for the partnership. 

8 (E) TREATMENT AS PUBLIC HEALTH AU9 THORITY FOR PURPOSES OF HIPAA.—For pur10 poses of applying HIPAA privacy and security 

11 law (as defined in section 3009(a)(2) of the 

12 Public Health Service Act (42 U.S.C. 300jj– 

13 19)), each State maternal mortality review com14 mittee and regional maternal mortality review 

15 committee established under subsection (a)(1) 

16 or subsection (b)(2)(D), as the case may be, 

17 shall be deemed to be a public health authority 

18 described in section 164.501 (and referenced in 

19 section 164.512(b)(1)(i)) of title 45, Code of 

20 Federal Regulations (or any successor regula21 tion), carrying out public health activities and 

22 purposes described in such section 

23 164.512(b)(1)(i) (or any such successor regula24 tion). 


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1 (3) STATE DEPARTMENT OF HEALTH ACTIVI2 TIES.—With respect to a State that receives a grant 

3 under subsection (a)(1), the State department of 

4 health shall— 

5 (A) in consultation with the State maternal 

6 mortality review committee and in conjunction 

7 with relevant professional organizations and pa8 tient advocacy organizations, develop a plan for 

9 ongoing health care provider education, based 

10 on the findings and recommendations of the 

11 committee, in order to improve the quality of 

12 maternal care; and 

13 (B) take steps to widely disseminate the 

14 findings and recommendations of the State ma15 ternal mortality review committee and imple16 ment the recommendations of the committee. 

17 (c) CASE ABSTRACTION FORM.— 

18 (1) DISSEMINATION.—The Director of the Cen19 ters for Disease Control and Prevention shall dis20 seminate a uniform case abstraction form to States 

21 and State maternal mortality review committees for 

22 the purpose of— 

23 (A) ensuring that the data and information 

24 collected and reviewed by such committees can 

25 be pooled for review by the Department of 


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1 Health and Human Services and its agencies; 

2 and 

3 (B) preserving the uniformity of the infor4 mation collected for Federal public health pur5 poses. 

6 (2) PERMISSIBLE STATE MODIFICATION.—Each 

7 State may modify the form developed under para8 graph (1) for implementation and use by such State 

9 or by the State maternal mortality review committee 

10 of such State by including on such form additional 

11 information to be collected, but may not alter the 

12 standard questions on such form, in order to ensure 

13 that the information can be collected and reviewed 

14 centrally at the Federal level. 

15 (d) PUBLIC DISCLOSURE OF INFORMATION.— 

16 (1) IN GENERAL.—For fiscal year 2019, or a 

17 subsequent fiscal year, each State receiving a grant 

18 under this section for such year shall, subject to 

19 paragraph (3), provide for the public disclosure, and 

20 submission to the information clearinghouse estab21 lished under paragraph (2), of the information in22 cluded in the report of the State under subsection 

23 (f)(1) for such year. 

24 (2) INFORMATION CLEARINGHOUSE.—The Sec25 retary shall establish an information clearinghouse, 


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1 to be administered by the Director of the Centers for 

2 Disease Control and Prevention, that will maintain 

3 findings and recommendations submitted pursuant 

4 to paragraph (1) and provide such findings and rec5 ommendations for public review and research pur6 poses by State departments of health, State mater7 nal mortality review committees, health providers 

8 and institutions, and national patient and provider 

9 advocacy groups. 

10 (3) CONFIDENTIALITY OF INFORMATION.—In 

11 no case may any individually identifiable health in12 formation be provided to the public, or submitted to 

13 the information clearinghouse, under this subsection. 

14 (e) CONFIDENTIALITY OF PROCEEDINGS OF STATE

15 MATERNAL MORTALITY REVIEW COMMITTEES.— 

16 (1) IN GENERAL.—All proceedings and activi17 ties of a State maternal mortality review committee 

18 established under subsection (a)(1), opinions of 

19 members of such a committee formed as a result of 

20 such proceedings and activities, and records ob21 tained, created, or maintained pursuant to this sec22 tion, including records of interviews, written reports, 

23 and statements procured by the Department of 

24 Health and Human Services or by any other person, 

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1 partment, in connection with morbidity and mor2 tality reviews under this section, shall be confidential 

3 and may not be subject to discovery, subpoena, or 

4 introduction into evidence in any civil, criminal, leg5 islative, or other proceeding. Such records shall not 

6 be open to public inspection. 

7 (2) TESTIMONY OF MEMBERS OF COM8 MITTEE.— 

9 (A) IN GENERAL.—Members of a State 

10 maternal mortality review committee established 

11 under subsection (a)(1) may not be questioned 

12 in any civil, criminal, legislative, or other pro13 ceeding regarding information presented in, or 

14 opinions formed as a result of, a meeting or 

15 communication of the committee. 

16 (B) CLARIFICATION.—Nothing in this sub17 section may be construed to prevent a member 

18 of a State maternal mortality review committee 

19 established under subsection (a)(1) from testi20 fying regarding information that was obtained 

21 independent of such member’s participation on 

22 the committee, or public information. 

23 (3) AVAILABILITY OF INFORMATION FOR RE24 SEARCH PURPOSES.—Nothing in this subsection may 

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1 mittee established under subsection (a)(1) or the De2 partment of Health and Human Services from pub3 lishing statistical compilations and research reports 

4 that— 

5 (A) are based on confidential information, 

6 relating to morbidity and mortality reviews 

7 under this section; and 

8 (B) do not contain identifying information 

9 or any other information that could be used to 

10 ultimately identify the individuals concerned. 

11 (f) REPORTS.— 

12 (1) STATE REPORTS.—Not later than one year 

13 after the end of fiscal year 2019, and each subse14 quent fiscal year, each State maternal mortality re15 view committee established under subsection (a)(1) 

16 and receiving a grant under this section for such 

17 year, shall submit to the Director of the Centers for 

18 Disease Control and Prevention a report on the find19 ings and recommendations of such committee and 

20 information on the implementation of such rec21 ommendations during such year. 

22 (2) ANNUAL REPORTS TO CONGRESS.—Not 

23 later than 60 days after the deadline for State re24 ports under paragraph (1) for fiscal year 2019, and 

25 each subsequent fiscal year, the Secretary of Health 


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1 and Human Services shall submit to Congress a re2 port on— 

3 (A) the findings, recommendations, and 

4 implementation information submitted by any 

5 State pursuant to paragraph (1); and 

6 (B) the status of pregnancy-related and 

7 pregnancy-associated deaths in the United 

8 States, including recommendations on methods 

9 to prevent such deaths in the United States. 

10 (g) DEFINITIONS.—In this section: 

11 (1) The term ‘‘pregnancy-associated death’’ 

12 means the death of a person while pregnant or dur13 ing the one-year period following the date of the end 

14 of pregnancy, irrespective of the cause of such death. 

15 (2) The term ‘‘pregnancy-related death’’ means 

16 the death of a person while pregnant or during the 

17 one-year period following the date of the end of 

18 pregnancy, irrespective of the duration of the preg19 nancy, from any cause related to, or aggravated by, 

20 the pregnancy or its management, excluding any ac21 cidental or incidental cause. 

22 (3) The term ‘‘severe maternal morbidity’’ 

23 means the physical and psychological conditions that 

24 result from, or are aggravated by, pregnancy and 

25 have an adverse effect on the health of a person. 


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1 (4) The term ‘‘State’’ means each of the 50 

2 States, the District of Columbia, and each of the 

3 territories. 

4 (5) The term ‘‘vital statistics unit’’ means the 

5 entity that is responsible for maintaining vital 

6 records for a State, including official records of live 

7 births, deaths, fetal deaths, marriages, divorces, and 

8 annulments. 

9 (h) AUTHORIZATION OF APPROPRIATIONS.—There is 

10 authorized to be appropriated to carry out this section 

11 $7,000,000 for each of fiscal years 2019 through 2023. 

12 SEC. 506. ELIMINATING DISPARITIES IN MATERNITY 

13 HEALTH OUTCOMES. 

14 Part B of title III of the Public Health Service Act 

15 is amended by inserting after section 317V of such Act, 

16 as added, the following new section: 

17 ‘‘SEC. 317W. ELIMINATING DISPARITIES IN MATERNAL 

18 HEALTH OUTCOMES. 

19 ‘‘(a) IN GENERAL.—The Secretary shall, in consulta20 tion with relevant national stakeholder organizations, such 

21 as national medical specialty organizations, national ma22 ternal child health organizations, national patient advo23 cacy organizations, and national health disparity organiza24 tions, carry out the following activities to eliminate dis25 parities in maternal health outcomes: 


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1 ‘‘(1) Conduct research into the determinants 

2 and the distribution of disparities in maternal care, 

3 health risks, and health outcomes, and improve the 

4 capacity of the performance measurement infrastruc5 ture to measure such disparities. 

6 ‘‘(2) Expand access to health care services, re7 sources, and information that have been dem8 onstrated to improve the quality and outcomes of 

9 maternity care for vulnerable populations. 

10 ‘‘(3) Establish a demonstration project to com11 pare the effectiveness of interventions to reduce dis12 parities in maternity services and outcomes and to 

13 implement and assess effective interventions. 

14 ‘‘(b) SCOPE AND SELECTION OF STATES FOR DEM15 ONSTRATION PROJECT.—The demonstration project 

16 under subsection (a)(3) shall be conducted in no more 

17 than 8 States, which shall be selected by the Secretary 

18 based on— 

19 ‘‘(1) applications submitted by States, which 

20 specify which regions and populations the State in21 volved will serve under the demonstration project; 

22 ‘‘(2) criteria designed by the Secretary to en23 sure that, as a whole, the demonstration project is, 

24 to the greatest extent possible, representative of the 


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1 demographic and geographic composition of commu2 nities most affected by disparities; 

3 ‘‘(3) criteria designed by the Secretary to en4 sure that a variety of models are tested through the 

5 demonstration project and that such models include 

6 interventions that have an existing evidence base for 

7 effectiveness; and 

8 ‘‘(4) criteria designed by the Secretary to en9 sure that the demonstration projects and models will 

10 be carried out in consultation with local and regional 

11 provider organizations, such as community health 

12 centers, hospital systems, and medical societies rep13 resenting providers of maternity services. 

14 ‘‘(c) DURATION OF DEMONSTRATION PROJECT.— 

15 The demonstration project under subsection (a)(3) shall 

16 begin on January 1, 2019, and end on December 31, 

17 2022. 

18 ‘‘(d) GRANTS FOR EVALUATION AND MONITORING.— 

19 The Secretary may make grants to States and health care 

20 providers participating in the demonstration project under 

21 subsection (a)(3) for the purpose of collecting data nec22 essary for the evaluation and monitoring of such project. 

23 ‘‘(e) REPORTS.— 

24 ‘‘(1) STATE REPORTS.—Each State that par25 ticipates in the demonstration project under subVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00360 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 section (a)(3) shall report to the Secretary, in a 

2 time, form, and manner specified by the Secretary, 

3 the data necessary to— 

4 ‘‘(A) monitor the— 

5 ‘‘(i) outcomes of the project; 

6 ‘‘(ii) costs of the project; and 

7 ‘‘(iii) quality of maternity care pro8 vided under the project; and 

9 ‘‘(B) evaluate the rationale for the selec10 tion of the items and services included in any 

11 bundled payment made by the State under the 

12 project. 

13 ‘‘(2) FINAL REPORT.—Not later than December 

14 31, 2022, the Secretary shall submit to Congress a 

15 report on the results of the demonstration project 

16 under subsection (a)(3).’’. 

17 SEC. 507. DECREASING THE RISK FACTORS FOR SUDDEN 

18 UNEXPECTED INFANT DEATH AND SUDDEN 

19 UNEXPLAINED DEATH IN CHILDHOOD. 

20 (a) ESTABLISHMENT.—The Secretary of Health and 

21 Human Services, acting through the Administrator of the 

22 Health Resources and Services Administration and in con23 sultation with the Director of the Centers for Disease Con24 trol and Prevention and the Director of the National Insti25 tutes of Health (in this section referred to as the ‘‘SecVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00361 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 retary’’), shall establish and implement a culturally and 

2 linguistically competent public health awareness and edu3 cation campaign to provide information that is focused on 

4 decreasing the risk factors for sudden unexpected infant 

5 death and sudden unexplained death in childhood, includ6 ing educating individuals about safe sleep environments, 

7 sleep positions, and reducing exposure to smoking during 

8 pregnancy and after birth. 

9 (b) TARGETED POPULATIONS.—The campaign under 

10 subsection (a) shall be designed to reduce health dispari11 ties through the targeting of populations with high rates 

12 of sudden unexpected infant death and sudden unex13 plained death in childhood. 

14 (c) CONSULTATION.—In establishing and imple15 menting the campaign under subsection (a), the Secretary 

16 shall consult with national organizations representing 

17 health care providers, including nurses and physicians, 

18 parents, child care providers, children’s advocacy and safe19 ty organizations, maternal and child health programs, nu20 trition professionals focusing on women, infants, and chil21 dren, and other individuals and groups determined nec22 essary by the Secretary for such establishment and imple23 mentation. 

24 (d) GRANTS.— 


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1 (1) IN GENERAL.—In carrying out the cam2 paign under subsection (a), the Secretary shall 

3 award grants to national organizations, State and 

4 local health departments, and community-based or5 ganizations for the conduct of education and out6 reach programs for nurses, parents, child care pro7 viders, public health agencies, and community orga8 nizations. 

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

10 grant under paragraph (1), an entity shall submit to 

11 the Secretary an application at such time, in such 

12 manner, and containing such information as the Sec13 retary may require. 

14 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

15 authorized to be appropriated to carry out this section 

16 such sums as may be necessary for each of fiscal years 

17 2019 through 2023. 

18 SEC. 508. REDUCING UNINTENDED TEENAGE PREG19 NANCIES. 

20 Title III of the Public Health Service Act (42 U.S.C. 

21 241 et seq.) is amended by adding at the end the following 

22 new part: 


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1 ‘‘PART W—YOUTH ACCESS TO SEXUAL HEALTH 

2 SERVICES 

3 ‘‘SEC. 399OO. AUTHORIZATION OF GRANTS TO SUPPORT 

4 THE ACCESS OF MARGINALIZED YOUTH TO 

5 SEXUAL HEALTH SERVICES. 

6 ‘‘(a) GRANTS.—The Secretary of Health and Human 

7 Services may award grants on a competitive basis to eligi8 ble entities to support the access of marginalized youth 

9 to sexual health services. 

10 ‘‘(b) USE OF FUNDS.—An eligible entity that is 

11 awarded a grant under subsection (a) may use the funds 

12 to— 

13 ‘‘(1) provide medically accurate and complete 

14 and age-, developmentally, and culturally appro15 priate sexual health information to marginalized 

16 youth, including information on how to access sexual 

17 health services; 

18 ‘‘(2) promote effective communication regarding 

19 sexual health among marginalized youth; 

20 ‘‘(3) promote and support better health, edu21 cation, and economic opportunities for school-age 

22 parents; and 

23 ‘‘(4) train individuals who work with 

24 marginalized youth to promote— 

25 ‘‘(A) the prevention of unintended preg26 nancy; 


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1 ‘‘(B) the prevention of sexually transmitted 

2 infections, including the human immuno3 deficiency virus (HIV); 

4 ‘‘(C) healthy relationships; and 

5 ‘‘(D) the development of safe and sup6 portive environments. 

7 ‘‘(c) APPLICATION.—To be awarded a grant under 

8 subsection (a), an eligible entity shall submit an applica9 tion to the Secretary at such time, in such manner, and 

10 containing such information as the Secretary may require. 

11 ‘‘(d) PRIORITY.—In awarding grants under sub12 section (a), the Secretary shall give priority to eligible enti13 ties— 

14 ‘‘(1) with a history of supporting the access of 

15 marginalized youth to sexuality education or sexual 

16 health services; and 

17 ‘‘(2) that plan to serve marginalized youth that 

18 are not served by Federal adolescent programs for 

19 the prevention of pregnancy, HIV, and other sexu20 ally transmitted infections. 

21 ‘‘(e) REQUIREMENTS.—The Secretary may not award 

22 a grant under subsection (a) to an eligible entity unless— 

23 ‘‘(1) such eligible entity has formed a partner24 ship with a community organization; and 

25 ‘‘(2) such eligible entity agrees— 


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1 ‘‘(A) to employ a scientifically effective 

2 strategy; 

3 ‘‘(B) that all information provided to 

4 marginalized youth will be— 

5 ‘‘(i) age- and developmentally appro6 priate; 

7 ‘‘(ii) medically accurate and complete; 

8 ‘‘(iii) scientifically based; and 

9 ‘‘(iv) provided in the language and 

10 cultural context that is most appropriate 

11 for the individuals served by the eligible 

12 entity; and 

13 ‘‘(C) that for each year the eligible entity 

14 receives grant funds under subsection (a), the 

15 eligible entity will submit to the Secretary an 

16 annual report that includes— 

17 ‘‘(i) the use of grant funds by the eli18 gible entity; 

19 ‘‘(ii) how the use of grant funds has 

20 increased the access of marginalized youth 

21 to sexual health services; and 

22 ‘‘(iii) such other information as the 

23 Secretary may require. 

24 ‘‘(f) PUBLICATION AND EVALUATIONS.— 


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1 ‘‘(1) EVALUATIONS.—Not less than once every 

2 two years after the date of the enactment of this 

3 Act, the Secretary shall evaluate the effectiveness of 

4 whichever of the following is greater: 

5 ‘‘(A) Eight grants awarded under sub6 section (a). 

7 ‘‘(B) Ten percent of the grants awarded 

8 under subsection (a). 

9 ‘‘(2) PUBLICATION.—The Secretary shall make 

10 available to the public— 

11 ‘‘(A) the evaluations required under para12 graph (1); and 

13 ‘‘(B) the reports required under subsection 

14 (e)(2)(C). 

15 ‘‘(g) LIMITATIONS.—No funds made available to an 

16 eligible entity under this section may be used by such enti17 ty to provide access to sexual health services that— 

18 ‘‘(1) withhold sexual health-promoting or life19 saving information; 

20 ‘‘(2) are medically inaccurate or have been sci21 entifically shown to be ineffective; 

22 ‘‘(3) promote gender stereotypes; 

23 ‘‘(4) are insensitive or unresponsive to the 

24 needs of young people, including— 


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1 ‘‘(A) youth with varying gender identities, 

2 gender expressions, and sexual orientations; 

3 ‘‘(B) sexually active youth; 

4 ‘‘(C) pregnant or parenting youth; 

5 ‘‘(D) survivors of sexual abuse or assault; 

6 and 

7 ‘‘(E) youth of all physical, developmental, 

8 and mental abilities; or 

9 ‘‘(5) are inconsistent with the ethical impera10 tives of medicine and public health. 

11 ‘‘(h) TRANSFER OF FUNDS.—Any unobligated bal12 ance of funds made available under section 510(d) of the 

13 Social Security Act (42 U.S.C. 710(d)) (as in effect on 

14 the day before the date of the enactment of this Act) are 

15 hereby transferred and made available to the Secretary to 

16 carry out this Act. The amounts transferred and made 

17 available to carry out this Act shall remain available until 

18 expended. 

19 ‘‘(i) DEFINITIONS.—In this section: 

20 ‘‘(1) COMMUNITY ORGANIZATION.—The term 

21 ‘community organization’ includes a State or local 

22 health or education agency, public school, youth-fo23 cused organization that is faith-based and commu24 nity-based, juvenile justice entity, or other organiza25 tion that provides confidential and appropriate sexuVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00368 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 ality education or sexual health services to 

2 marginalized youth. 

3 ‘‘(2) ELIGIBLE ENTITY.—The term ‘eligible en4 tity’ includes a State or local health or education 

5 agency, public school, nonprofit organization, hos6 pital, or an Indian Tribe or Tribal organization (as 

7 such terms are defined in section 4 of the Indian 

8 Self-Determination and Education Assistance Act 

9 (25 U.S.C. 5304)). 

10 ‘‘(3) MARGINALIZED YOUTH.—The term 

11 ‘marginalized youth’ means a person under the age 

12 of 26 that is disadvantaged by underlying structural 

13 barriers and social inequity. 

14 ‘‘(4) MEDICALLY ACCURATE AND COMPLETE.— 

15 The term ‘medically accurate and complete’, when 

16 used with respect to information, means information 

17 that— 

18 ‘‘(A) is supported by research and recog19 nized as accurate, objective, and complete by 

20 leading medical, psychological, psychiatric, or 

21 public health organizations and agencies; and 

22 ‘‘(B) does not withhold any information re23 lating to the effectiveness and benefits of cor24 rect and consistent use of condoms or other 


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1 contraceptives and pregnancy prevention meth2 ods. 

3 ‘‘(5) SCIENTIFICALLY EFFECTIVE STRATEGY.— 

4 The term ‘scientifically effective strategy’ means a 

5 strategy that— 

6 ‘‘(A) is widely recognized by leading med7 ical and public health agencies as effective in 

8 promoting sexual health awareness and healthy 

9 behavior; and 

10 ‘‘(B) either— 

11 ‘‘(i) has been demonstrated to be ef12 fective on the basis of rigorous scientific 

13 research; or 

14 ‘‘(ii) incorporates characteristics of ef15 fective programs. 

16 ‘‘(6) SECRETARY.—The term ‘Secretary’ means 

17 the Secretary of Health and Human Services. 

18 ‘‘(7) SEXUAL HEALTH SERVICES.—The term 

19 ‘sexual health services’ includes— 

20 ‘‘(A) sexual health information, education, 

21 and counseling; 

22 ‘‘(B) contraception; 

23 ‘‘(C) emergency contraception; 


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1 ‘‘(D) condoms and other barrier methods 

2 to prevent pregnancy or sexually transmitted in3 fections; 

4 ‘‘(E) routine gynecological care, including 

5 human papillomavirus (HPV) vaccines and can6 cer screenings; 

7 ‘‘(F) pre-exposure prophylaxis or post-ex8 posure prophylaxis; 

9 ‘‘(G) mental health services; 

10 ‘‘(H) sexual assault survivor services; and 

11 ‘‘(I) other prevention, care, or treatment.’’. 

12 SEC. 509. GESTATIONAL DIABETES. 

13 Part B of title III of the Public Health Service Act 

14 (42 U.S.C. 243 et seq.) is amended by adding after section 

15 317H the following: 

16 ‘‘SEC. 317H–1. GESTATIONAL DIABETES. 

17 ‘‘(a) UNDERSTANDING AND MONITORING GESTA18 TIONAL DIABETES.— 

19 ‘‘(1) IN GENERAL.—The Secretary, acting 

20 through the Director of the Centers for Disease 

21 Control and Prevention, in consultation with the Di22 abetes Mellitus Interagency Coordinating Committee 

23 established under section 429 and representatives of 

24 appropriate national health organizations, shall de25 velop a multisite gestational diabetes research 


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1 project within the diabetes program of the Centers 

2 for Disease Control and Prevention to expand and 

3 enhance surveillance data and public health research 

4 on gestational diabetes. 

5 ‘‘(2) AREAS TO BE ADDRESSED.—The research 

6 project developed under paragraph (1) shall ad7 dress— 

8 ‘‘(A) procedures to establish accurate and 

9 efficient systems for the collection of gestational 

10 diabetes data within each State and common11 wealth, territory, or possession of the United 

12 States; 

13 ‘‘(B) the progress of collaborative activities 

14 with the National Vital Statistics System, the 

15 National Center for Health Statistics, and 

16 State health departments with respect to the 

17 standard birth certificate, in order to improve 

18 surveillance of gestational diabetes; 

19 ‘‘(C) postpartum methods of tracking indi20 viduals with gestational diabetes after delivery 

21 as well as targeted interventions proven to 

22 lower the incidence of type 2 diabetes in that 

23 population; 

24 ‘‘(D) variations in the distribution of diag25 nosed and undiagnosed gestational diabetes, 


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1 and of impaired fasting glucose tolerance and 

2 impaired fasting glucose, within and among 

3 groups of pregnant individuals; and 

4 ‘‘(E) factors and culturally sensitive inter5 ventions that influence risks and reduce the in6 cidence of gestational diabetes and related com7 plications during childbirth, including cultural, 

8 behavioral, racial, ethnic, geographic, demo9 graphic, socioeconomic, and genetic factors. 

10 ‘‘(3) REPORT.—Not later than 2 years after the 

11 date of the enactment of this section, and annually 

12 thereafter, the Secretary shall generate a report on 

13 the findings and recommendations of the research 

14 project including prevalence of gestational diabetes 

15 in the multisite area and disseminate the report to 

16 the appropriate Federal and non-Federal agencies. 

17 ‘‘(b) EXPANSION OF GESTATIONAL DIABETES RE18 SEARCH.— 

19 ‘‘(1) IN GENERAL.—The Secretary shall expand 

20 and intensify public health research regarding gesta21 tional diabetes. Such research may include— 

22 ‘‘(A) developing and testing novel ap23 proaches for improving postpartum diabetes 

24 testing or screening and for preventing type 2 


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1 diabetes in individuals who can become preg2 nant with a history of gestational diabetes; and 

3 ‘‘(B) conducting public health research to 

4 further understanding of the epidemiologic, 

5 socioenvironmental, behavioral, translation, and 

6 biomedical factors and health systems that in7 fluence the risk of gestational diabetes and the 

8 development of type 2 diabetes in individuals 

9 who can become pregnant with a history of ges10 tational diabetes. 

11 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

12 There is authorized to be appropriated to carry out 

13 this subsection $5,000,000 for each of fiscal years 

14 2019 through 2023. 

15 ‘‘(c) DEMONSTRATION GRANTS TO LOWER THE

16 RATE OF GESTATIONAL DIABETES.— 

17 ‘‘(1) IN GENERAL.—The Secretary, acting 

18 through the Director of the Centers for Disease 

19 Control and Prevention, shall award grants, on a 

20 competitive basis, to eligible entities for demonstra21 tion projects that implement evidence-based inter22 ventions to reduce the incidence of gestational diabe23 tes, the recurrence of gestational diabetes in subse24 quent pregnancies, and the development of type 2 diVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00374 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 abetes in individuals who can become pregnant with 

2 a history of gestational diabetes. 

3 ‘‘(2) PRIORITY.—In making grants under this 

4 subsection, the Secretary shall give priority to 

5 projects focusing on— 

6 ‘‘(A) helping individuals who can become 

7 pregnant who have 1 or more risk factors for 

8 developing gestational diabetes; 

9 ‘‘(B) working with individuals who can be10 come pregnant with a history of gestational dia11 betes during a previous pregnancy; 

12 ‘‘(C) providing postpartum care for indi13 viduals who can become pregnant with gesta14 tional diabetes; 

15 ‘‘(D) tracking cases where individuals who 

16 can become pregnant with a history of gesta17 tional diabetes developed type 2 diabetes; 

18 ‘‘(E) educating mothers with a history of 

19 gestational diabetes about the increased risk of 

20 their child developing diabetes; 

21 ‘‘(F) working to prevent gestational diabe22 tes and prevent or delay the development of 

23 type 2 diabetes in individuals who can become 

24 pregnant with a history of gestational diabetes; 

25 and 


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1 ‘‘(G) achieving outcomes designed to assess 

2 the efficacy and cost-effectiveness of interven3 tions that can inform decisions on long-term 

4 sustainability, including third-party reimburse5 ment. 

6 ‘‘(3) APPLICATION.—An eligible entity desiring 

7 to receive a grant under this subsection shall submit 

8 to the Secretary— 

9 ‘‘(A) an application at such time, in such 

10 manner, and containing such information as the 

11 Secretary may require; and 

12 ‘‘(B) a plan to— 

13 ‘‘(i) lower the rate of gestational dia14 betes during pregnancy; or 

15 ‘‘(ii) develop methods of tracking indi16 viduals who can become pregnant with a 

17 history of gestational diabetes and develop 

18 effective interventions to lower the inci19 dence of the recurrence of gestational dia20 betes in subsequent pregnancies and the 

21 development of type 2 diabetes. 

22 ‘‘(4) USES OF FUNDS.—An eligible entity re23 ceiving a grant under this subsection shall use the 

24 grant funds to carry out demonstration projects de25 scribed in paragraph (1), including— 


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1 ‘‘(A) expanding community-based health 

2 promotion education, activities, and incentives 

3 focused on the prevention of gestational diabe4 tes and development of type 2 diabetes in indi5 viduals who can become pregnant with a history 

6 of gestational diabetes; 

7 ‘‘(B) aiding State- and Tribal-based diabe8 tes prevention and control programs to collect, 

9 analyze, disseminate, and report surveillance 

10 data on individuals who can become pregnant 

11 with, and at risk for, gestational diabetes, the 

12 recurrence of gestational diabetes in subsequent 

13 pregnancies, and, for individuals who can be14 come pregnant with a history of gestational dia15 betes, the development of type 2 diabetes; and 

16 ‘‘(C) training and encouraging health care 

17 providers— 

18 ‘‘(i) to promote risk assessment, high19 quality care, and self-management for ges20 tational diabetes and the recurrence of ges21 tational diabetes in subsequent preg22 nancies; and 

23 ‘‘(ii) to prevent the development of 

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1 tional diabetes, and its complications in the 

2 practice settings of the health care pro3 viders. 

4 ‘‘(5) REPORT.—Not later than 4 years after the 

5 date of the enactment of this section, the Secretary 

6 shall prepare and submit to the Congress a report 

7 concerning the results of the demonstration projects 

8 conducted through the grants awarded under this 

9 subsection. 

10 ‘‘(6) DEFINITION OF ELIGIBLE ENTITY.—In 

11 this subsection, the term ‘eligible entity’ means a 

12 nonprofit organization (such as a nonprofit academic 

13 center or community health center) or a State, Trib14 al, or local health agency. 

15 ‘‘(7) AUTHORIZATION OF APPROPRIATIONS.— 

16 There is authorized to be appropriated to carry out 

17 this subsection $5,000,000 for each of fiscal years 

18 2019 through 2023. 

19 ‘‘(d) POSTPARTUM FOLLOWUP REGARDING GESTA20 TIONAL DIABETES.—The Secretary, acting through the 

21 Director of the Centers for Disease Control and Preven22 tion, shall work with the State- and Tribal-based diabetes 

23 prevention and control programs assisted by the Centers 

24 to encourage postpartum followup after gestational diabe25 tes, as medically appropriate, for the purpose of reducing 


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1 the incidence of gestational diabetes, the recurrence of 

2 gestational diabetes in subsequent pregnancies, the devel3 opment of type 2 diabetes in individuals with a history 

4 of gestational diabetes, and related complications.’’. 

5 SEC. 510. EMERGENCY CONTRACEPTION EDUCATION AND 

6 INFORMATION PROGRAMS. 

7 (a) EMERGENCY CONTRACEPTION PUBLIC EDU8 CATION PROGRAM.— 

9 (1) IN GENERAL.—The Secretary, acting 

10 through the Director of the Centers for Disease 

11 Control and Prevention, shall develop and dissemi12 nate to the public medically accurate and complete 

13 information on emergency contraception. 

14 (2) DISSEMINATION.—The Secretary may dis15 seminate medically accurate and complete informa16 tion under paragraph (1) directly or through ar17 rangements with nonprofit organizations, community 

18 health workers including promotoras, consumer 

19 groups, institutions of higher education, clinics, the 

20 media, and Federal, State, and local agencies. 

21 (3) INFORMATION.—The information dissemi22 nated under paragraph (1) shall— 

23 (A) include, at a minimum, a description 

24 of emergency contraception and an explanation 

25 of the use, safety, efficacy, and availability of 


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1 such contraception and options for no-copay ac2 cess through insurance; and 

3 (B) be pilot tested for consumer com4 prehension, cultural and linguistic appropriate5 ness, and acceptance of the messages across 

6 geographically, racially, ethnically, and linguis7 tically diverse populations. 

8 (b) EMERGENCY CONTRACEPTION INFORMATION

9 PROGRAM FOR HEALTH CARE PROVIDERS.— 

10 (1) IN GENERAL.—The Secretary, acting 

11 through the Administrator of the Health Resources 

12 and Services Administration and in consultation 

13 with major medical and public health organizations, 

14 shall develop and disseminate to health care pro15 viders information on emergency contraception. 

16 (2) INFORMATION.—The information dissemi17 nated under paragraph (1) shall include, at a min18 imum— 

19 (A) information describing the use, safety, 

20 efficacy, availability of emergency contraception, 

21 and options for no-copay access through insur22 ance; 

23 (B) a recommendation regarding the use of 

24 such contraception; and 


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1 (C) information explaining how to obtain 

2 copies of the information developed under sub3 section (a) for distribution to the patients of 

4 the providers. 

5 (c) DEFINITIONS.—In this section: 

6 (1) EMERGENCY CONTRACEPTION.—The term 

7 ‘‘emergency contraception’’ means a drug or device 

8 (as the terms are defined in section 201 of the Fed9 eral Food, Drug, and Cosmetic Act (21 U.S.C. 321)) 

10 or a drug regimen that— 

11 (A) is used postcoitally; 

12 (B) prevents pregnancy primarily by pre13 venting or delaying ovulation, and does not ter14 minate an established pregnancy; and 

15 (C) is approved by the Food and Drug Ad16 ministration. 

17 (2) HEALTH CARE PROVIDER.—The term 

18 ‘‘health care provider’’ means an individual who is li19 censed or certified under State law to provide health 

20 care services and who is operating within the scope 

21 of such license. Such term shall include a phar22 macist. 

23 (3) INSTITUTION OF HIGHER EDUCATION.—The 

24 term ‘‘institution of higher education’’ has the same 


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1 meaning given such term in section 101(a) of the 

2 Higher Education Act of 1965 (20 U.S.C. 1001(a)). 

3 (4) MEDICALLY ACCURATE AND COMPLETE.— 

4 The term ‘‘medically accurate and complete’’ means, 

5 with respect to information, activities, or services 

6 verified or supported by the weight of research con7 ducted in compliance with accepted scientific meth8 ods and— 

9 (A) published in peer-reviewed journals, 

10 where applicable; or 

11 (B) comprising information that leading 

12 professional organizations and agencies with 

13 relevant expertise in the field recognize as accu14 rate, objective, and complete. 

15 (5) SECRETARY.—The term ‘‘Secretary’’ means 

16 the Secretary of Health and Human Services. 

17 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

18 are authorized to be appropriated to carry out this section 

19 such sums as may be necessary for each of the fiscal years 

20 2019 through 2023. 

21 SEC. 511. COMPREHENSIVE SEX EDUCATION PROGRAMS. 

22 (a) PURPOSES; FINDING; SENSE OF CONGRESS.— 

23 (1) PURPOSES.—The purposes of this Act are 

24 to provide young people with comprehensive sex edu25 cation programs that— 


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1 (A) promote and uphold the rights of 

2 young people to information in order to make 

3 healthy decisions about their sexual health; 

4 (B) provide the information and skills all 

5 young people need to make informed, respon6 sible, and healthy decisions in order to become 

7 sexually healthy adults and have healthy rela8 tionships; 

9 (C) provide information about the preven10 tion of unintended pregnancy, sexually trans11 mitted infections, including HIV, dating vio12 lence, sexual assault, bullying, and harassment; 

13 and 

14 (D) provide resources and information on 

15 topics ranging from gender stereotyping and 

16 gender roles and stigma and socio-cultural in17 fluences surrounding sex and sexuality. 

18 (2) FINDING ON REQUIRED RESOURCES.—In 

19 order to provide the comprehensive sex education de20 scribed in paragraph (1), Congress finds that in21 creased resources are required for sex education pro22 grams that— 

23 (A) substantially incorporate elements of 

24 evidence-based programs or characteristics of 

25 effective programs; 


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1 (B) cover a broad range of topics, includ2 ing medically accurate and complete informa3 tion that is age and developmentally appro4 priate about all the aspects of sex, sexual 

5 health, and sexuality; 

6 (C) are gender and gender identity-sen7 sitive, emphasizing the importance of equality 

8 and the social environment for achieving sexual 

9 and reproductive health and overall well-being; 

10 (D) promote educational achievement, crit11 ical thinking, decisionmaking, self-esteem, and 

12 self-efficacy; 

13 (E) help develop healthy attitudes and in14 sights necessary for understanding relationships 

15 between oneself and others and society; 

16 (F) foster leadership skills and community 

17 engagement by— 

18 (i) promoting principles of fairness, 

19 human dignity, and respect; and 

20 (ii) engaging young people as partners 

21 in their communities; and 

22 (G) are culturally and linguistically appro23 priate, reflecting the diverse circumstances and 

24 realities of young people. 


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1 (3) SENSE OF CONGRESS.—It is the sense of 

2 Congress that— 

3 (A) federally funded sex education pro4 grams should aim to— 

5 (i) provide information about a range 

6 of human sexuality topics, including— 

7 (I) human development, healthy 

8 relationships, personal skills; 

9 (II) sexual behavior including ab10 stinence; 

11 (III) sexual health including pre12 venting unintended pregnancy; 

13 (IV) sexually transmitted infec14 tions including HIV; and 

15 (V) society and culture; 

16 (ii) promote safe and healthy relation17 ships; 

18 (iii) promote gender equity; 

19 (iv) use, and be informed by, the best 

20 scientific information available; 

21 (v) be culturally appropriate and in22 clusive of youth with varying gender identi23 ties, gender expressions, and sexual ori24 entations; 


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1 (vi) be built on characteristics of ef2 fective programs; 

3 (vii) expand the existing body of re4 search on comprehensive sex education 

5 programs through program evaluation; 

6 (viii) expand training programs for 

7 teachers of comprehensive sex education; 

8 (ix) build on programs funded under 

9 section 513 of the Social Security Act (42 

10 U.S.C. 713) and the Office of Adolescent 

11 Health’s Teen Pregnancy Prevention Pro12 gram, funded under title II of the Consoli13 dated Appropriations Act, 2010 (Public 

14 Law 111–117; 123 Stat.), and on pro15 grams supported through the Centers for 

16 Disease Control and Prevention (CDC); 

17 and 

18 (x) promote and uphold the rights of 

19 young people to information in order to 

20 make healthy and autonomous decisions 

21 about their sexual health; and 

22 (B) no Federal funds should be used for 

23 health education programs that— 


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1 (i) withhold health-promoting or life2 saving information about sexuality-related 

3 topics, including HIV; 

4 (ii) are medically inaccurate or have 

5 been scientifically shown to be ineffective; 

6 (iii) promote gender or racial stereo7 types; 

8 (iv) are insensitive and unresponsive 

9 to the needs of sexually active young peo10 ple; 

11 (v) are insensitive and unresponsive to 

12 the needs of survivors of sexual violence; 

13 (vi) are insensitive and unresponsive 

14 to the needs of youth of all physical, devel15 opmental, and mental abilities; 

16 (vii) are insensitive and unresponsive 

17 to the needs of youth with varying gender 

18 identities, gender expressions, and sexual 

19 orientations; or 

20 (viii) are inconsistent with the ethical 

21 imperatives of medicine and public health. 

22 (b) GRANTS FOR COMPREHENSIVE SEX EDUCATION

23 FOR ADOLESCENTS.— 

24 (1) PROGRAM AUTHORIZED.—The Secretary of 

25 Health and Human Services, in coordination with 


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1 the Associate Commissioner of the Family and 

2 Youth Services Bureau of the Administration on 

3 Children, Youth, and Families of the Department of 

4 Health and Human Services, the Director of the Of5 fice of Adolescent Health, the Director of the Divi6 sion of Adolescent and School Health within the 

7 Centers for Disease Control and Prevention and the 

8 Secretary of Education, shall award grants, on a 

9 competitive basis, to eligible entities to enable such 

10 eligible entities to carry out programs that provide 

11 adolescents with comprehensive sex education, as de12 scribed in paragraph (6). 

13 (2) DURATION.—Grants awarded under this 

14 section shall be for a period of 5 years. 

15 (3) ELIGIBLE ENTITY.—In this section, the 

16 term ‘‘eligible entity’’ means a public or private enti17 ty that focuses on adolescent health and education 

18 or has experience working with adolescents. 

19 (4) APPLICATIONS.—An eligible entity desiring 

20 a grant under this section shall submit an applica21 tion to the Secretary at such time, in such manner, 

22 and containing such information as the Secretary 

23 may require, including an assurance to participate in 

24 the evaluation described in subsection (e). 


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1 (5) PRIORITY.—In awarding grants under this 

2 section, the Secretary shall give priority to eligible 

3 entities that— 

4 (A) are State or local public entities; 

5 (B) are entities not currently receiving 

6 funds under— 

7 (i) section 513 of the Social Security 

8 Act (42 U.S.C. 713); 

9 (ii) the Office of Adolescent Health’s 

10 Teen Pregnancy Prevention Program, 

11 funded under title II of the Consolidated 

12 Appropriations Act, 2010 (Public Law– 

13 117; 123 Stat. 3253), or any substantially 

14 similar successive program; or 

15 (iii) the Centers for Disease Control 

16 and Prevention’s Division of Adolescent 

17 and School Health; and 

18 (C) address health inequities among young 

19 people that face systemic barriers resulting in 

20 disproportionate rates of not less than one of 

21 the following: 

22 (i) Unintended pregnancies. 

23 (ii) Sexually transmitted infections, 

24 including HIV. 


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1 (iii) Dating violence and sexual vio2 lence. 

3 (6) USE OF FUNDS.— 

4 (A) IN GENERAL.—Each eligible entity 

5 that receives a grant under this section shall 

6 use the grant funds to carry out an education 

7 program that provides adolescents with com8 prehensive sex education that— 

9 (i) is age and developmentally appro10 priate; 

11 (ii) is medically accurate and com12 plete; 

13 (iii) substantially incorporates ele14 ments of evidence-based sex education in15 struction; or 

16 (iv) creates a demonstration project 

17 based on characteristics of effective pro18 grams. 

19 (B) CONTENTS OF COMPREHENSIVE SEX

20 EDUCATION PROGRAMS.—The comprehensive 

21 sex education programs funded under this sec22 tion shall include instruction and materials that 

23 address— 

24 (i) the physical, social, and emotional 

25 changes of human development including, 


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1 human anatomy, reproduction, and sexual 

2 development; 

3 (ii) healthy relationships, including 

4 friendships, within families, and society, 

5 that are based on mutual respect, and the 

6 ability to distinguish between healthy and 

7 unhealthy relationships, including— 

8 (I) effective communication, ne9 gotiation and refusal skills, including 

10 the skills to recognize and report in11 appropriate or abusive sexual ad12 vances; 

13 (II) bodily autonomy, setting and 

14 respecting personal boundaries, prac15 ticing personal safety, and consent; 

16 and 

17 (III) the limitations and harm of 

18 gender-role stereotypes, violence, coer19 cion, bullying, harassment, and intimi20 dation in relationships; 

21 (iii) healthy decisionmaking skills 

22 about sexuality and relationships that in23 clude— 


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1 (I) critical thinking, problem 

2 solving, self-efficacy, stress-manage3 ment, self-care, and decisionmaking; 

4 (II) individual values and atti5 tudes; 

6 (III) the promotion of positive 

7 body images; 

8 (IV) developing an understanding 

9 that there are a range of body types 

10 and encouraging positive feeling about 

11 students’ own body types; 

12 (V) information on how to re13 spect others and ensure safety on the 

14 internet and when using other forms 

15 of digital communication; 

16 (VI) information on local services 

17 and resources where students can ob18 tain additional information related to 

19 bullying, harassment, dating violence 

20 and sexual assault, suicide prevention, 

21 and other related care; 

22 (VII) encouragement for youth to 

23 communicate with their parents or 

24 guardians, health and social service 

25 professionals, and other trusted adults 


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1 about sexuality and intimate relation2 ships; 

3 (VIII) information on how to cre4 ate a safe environment for all stu5 dents and others in society; 

6 (IX) examples of varying types of 

7 relationships, couples, and family 

8 structures; and 

9 (X) affirmative representation of 

10 varying gender identities, gender ex11 pressions, and sexual orientations, in12 cluding individuals and relationships 

13 between same sex couples and their 

14 families; 

15 (iv) abstinence, delaying age of first 

16 sexual activity, the use of condoms, preven17 tive medication, vaccination, birth control, 

18 and other sexually transmitted infection 

19 prevention measures, and the options for 

20 pregnancy, including parenting, adoption, 

21 and abortion, including— 

22 (I) the importance of effectively 

23 using condoms, preventive medication, 

24 and applicable vaccinations to protect 


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1 against sexually transmitted infec2 tions, including HIV; 

3 (II) the benefits of effective con4 traceptive and condom use in avoiding 

5 unintended pregnancy; 

6 (III) the relationship between 

7 substance use and sexual health and 

8 behaviors; and 

9 (IV) information about local 

10 health services where students can ob11 tain additional information and serv12 ices related to sexual and reproductive 

13 health and other related care; 

14 (v) through affirmative recognition, 

15 the roles that traditions, values, religion, 

16 norms, gender roles, acculturation, family 

17 structure, health beliefs, and political 

18 power play in how students make decisions 

19 that affect their sexual health, using exam20 ples of various types of races, ethnicities, 

21 cultures, and families, including single-par22 ent households and young families; 

23 (vi) information about gender identity, 

24 gender expression, and sexual orientation 

25 for all students, including— 


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1 (I) affirmative recognition that 

2 people have different gender identi3 ties, gender expressions, and sexual 

4 orientations; and 

5 (II) community resources that 

6 can provide additional support for in7 dividuals with varying gender identi8 ties, gender expressions, and sexual 

9 orientations; and 

10 (vii) opportunities to explore the roles 

11 that race, ethnicity, immigration status, 

12 disability status, economic status, home13 lessness, foster care status, and language 

14 within different communities affect sexual 

15 attitudes in society and culture and how 

16 this may impact student sexual health. 

17 (c) GRANTS FOR COMPREHENSIVE SEX EDUCATION

18 AT INSTITUTIONS OF HIGHER EDUCATION.— 

19 (1) PROGRAM AUTHORIZED.—The Secretary, in 

20 coordination with the Secretary of Education, shall 

21 award grants, on a competitive basis, to institutions 

22 of higher education or consortia of such institutions 

23 to enable such institutions to provide young people 

24 with comprehensive sex education, described in para25 graph (5)(B). 


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1 (2) DURATION.—Grants awarded under this 

2 section shall be for a period of 5 years. 

3 (3) APPLICATIONS.—An institution of higher 

4 education or consortia of such institutions desiring a 

5 grant under this section shall submit an application 

6 to the Secretary at such time, in such manner, and 

7 containing such information as the Secretary may 

8 require, including an assurance to participate in the 

9 evaluation described in subsection (e). 

10 (4) PRIORITY.—In awarding grants under this 

11 section, the Secretary shall give priority to an insti12 tution of higher education that— 

13 (A) has an enrollment of needy students as 

14 defined in section 318(b) of the Higher Edu15 cation Act of 1965 (20 U.S.C. 1059e(b)); 

16 (B) is a Hispanic-serving institution, as 

17 defined in section 502(a) of such Act (20 

18 U.S.C. 1101a(a)); 

19 (C) is a Tribal College or University, as 

20 defined in section 316(b) of such Act (20 

21 U.S.C. 1059c(b)); 

22 (D) is an Alaska Native-serving institution, 

23 as defined in section 317(b) of such Act (20 

24 U.S.C. 1059d(b)); 


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1 (E) is a Native Hawaiian-serving institu2 tion, as defined in section 317(b) of such Act 

3 (20 U.S.C. 1059d(b)); 

4 (F) is a Predominately Black Institution, 

5 as defined in section 318(b) of such Act (20 

6 U.S.C. 1059e(b)); 

7 (G) is a Native American-serving, non8 tribal institution, as defined in section 319(b) 

9 of such Act (20 U.S.C. 1059f(b)); 

10 (H) is an Asian American and Native 

11 American Pacific Islander-serving institution, as 

12 defined in section 320(b) of such Act (20 

13 U.S.C. 1059g(b)); or 

14 (I) is a minority institution, as defined in 

15 section 365 of such Act (20 U.S.C. 1067k), 

16 with an enrollment of needy students, as de17 fined in section 312 of such Act (20 U.S.C. 

18 1058). 

19 (5) USES OF FUNDS.— 

20 (A) IN GENERAL.—An institution of higher 

21 education receiving a grant under this section 

22 shall use grant funds to integrate issues relat23 ing to comprehensive sex education into institu24 tion of higher education in order to reach a 


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1 large number of students, by carrying out one 

2 or more of the following activities: 

3 (i) Developing or adopting educational 

4 content for issues relating to comprehen5 sive sex education that will be incorporated 

6 into student orientation, general education, 

7 or core courses. 

8 (ii) Developing or adopting, and im9 plementing schoolwide educational pro10 gramming outside of class that delivers ele11 ments of comprehensive sex education pro12 grams to students, faculty, and staff. 

13 (iii) Developing or adopting innovative 

14 technology-based approaches to deliver sex 

15 education to students, faculty, and staff. 

16 (iv) Developing or adopting, and im17 plementing peer-outreach and education 

18 programs to generate discussion, educate, 

19 and raise awareness among students about 

20 issues relating to comprehensive sex edu21 cation. 

22 (B) CONTENTS OF SEX EDUCATION PRO23 GRAMS.—Each institution of higher education’s 

24 program of comprehensive sex education funded 

25 under this section shall include instruction and 


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1 materials that address the requirements under 

2 paragraph 6. 

3 (d) GRANTS FOR PRE-SERVICE AND IN-SERVICE

4 TEACHER TRAINING.— 

5 (1) PROGRAM AUTHORIZED.—The Secretary, in 

6 coordination with the Director of the Centers for 

7 Disease Control and Prevention and the Secretary of 

8 Education, shall award grants, on a competitive 

9 basis, to eligible entities to enable such eligible enti10 ties to carry out the activities described in para11 graph (5). 

12 (2) DURATION.—Grants awarded under this 

13 section shall be for a period of 5 years. 

14 (3) ELIGIBLE ENTITY.—In this section, the 

15 term ‘‘eligible entity’’ means— 

16 (A) a State educational agency, as defined 

17 in section 8101 of the Elementary and Sec18 ondary Education of 1965 (20 U.S.C. 7801); 

19 (B) a local educational agency, as defined 

20 in section 8101 of the Elementary and Sec21 ondary Education of 1965 (20 U.S.C. 7801); 

22 (C) a Tribe or Tribal organization, as de23 fined in section 4 of the Indian Self-Determina24 tion and Education Assistance Act (25 U.S.C. 

25 5304); 


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1 (D) a State or local department of health; 

2 (E) a State or local department of edu3 cation; 

4 (F) an educational service agency, as de5 fined in section 8101 of the Elementary and 

6 Secondary Education of 1965 (20 U.S.C. 

7 7801); 

8 (G) a nonprofit institution of higher edu9 cation, as defined in section 101 of the Higher 

10 Education Act of 1965 (20 U.S.C. 1001); 

11 (H) a national or statewide nonprofit orga12 nization that has as its primary purpose the im13 provement of provision of comprehensive sex 

14 education through training and effective teach15 ing of comprehensive sex education; or 

16 (I) a consortium of nonprofit organizations 

17 that has as its primary purpose the improve18 ment of provision of comprehensive sex edu19 cation through training and effective teaching 

20 of comprehensive sex education. 

21 (4) APPLICATION.—An eligible entity desiring a 

22 grant under this section shall submit an application 

23 to the Secretary at such time, in such manner, and 

24 containing such information as the Secretary may 


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1 require, including an assurance to participate in the 

2 evaluation described in subsection (e). 

3 (5) AUTHORIZED ACTIVITIES.— 

4 (A) REQUIRED ACTIVITY.—Each eligible 

5 entity receiving a grant under this section shall 

6 use grant funds for professional development 

7 and training of relevant faculty, school adminis8 trators, teachers, and staff, in order to increase 

9 effective teaching of comprehensive sex edu10 cation students. 

11 (B) PERMISSIBLE ACTIVITIES.—Each eligi12 ble entity receiving a grant under this section 

13 may use grant funds to— 

14 (i) provide research-based training of 

15 teachers for comprehensive sex education 

16 for adolescents as a means of broadening 

17 student knowledge about issues related to 

18 human development, healthy relationships, 

19 personal skills, and sexual behavior, includ20 ing abstinence, sexual health, and society 

21 and culture; 

22 (ii) support the dissemination of infor23 mation on effective practices and research 

24 findings concerning the teaching of com25 prehensive sex education; 


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1 (iii) support research on— 

2 (I) effective comprehensive sex 

3 education teaching practices; and 

4 (II) the development of assess5 ment instruments and strategies to 

6 document— 

7 (aa) student understanding 

8 of comprehensive sex education; 

9 and 

10 (bb) the effects of com11 prehensive sex education; 

12 (iv) convene national conferences on 

13 comprehensive sex education, in order to 

14 effectively train teachers in the provision of 

15 comprehensive sex education; and 

16 (v) develop and disseminate appro17 priate research-based materials to foster 

18 comprehensive sex education. 

19 (C) SUBGRANTS.—Each eligible entity re20 ceiving a grant under this section may award 

21 subgrants to nonprofit organizations that pos22 sess a demonstrated record of providing train23 ing to faculty, school administrators, teachers, 

24 and staff on comprehensive sex education to— 


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1 (i) train teachers in comprehensive 

2 sex education; 

3 (ii) support Internet or distance learn4 ing related to comprehensive sex education; 

5 (iii) promote rigorous academic stand6 ards and assessment techniques to guide 

7 and measure student performance in com8 prehensive sex education; 

9 (iv) encourage replication of best 

10 practices and model programs to promote 

11 comprehensive sex education; 

12 (v) develop and disseminate effective, 

13 research-based comprehensive sex edu14 cation learning materials; 

15 (vi) develop academic courses on the 

16 pedagogy of sex education at institutions 

17 of higher education; or 

18 (vii) convene State-based conferences 

19 to train teachers in comprehensive sex edu20 cation and to identify strategies for im21 provement. 

22 (e) IMPACT EVALUATION AND REPORTING.— 

23 (1) MULTI-YEAR EVALUATION.— 

24 (A) IN GENERAL.—Not later than 6 

25 months after the date of the enactment of this 


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1 Act, the Secretary shall enter into a contract 

2 with a nonprofit organization with experience in 

3 conducting impact evaluations, to conduct a 

4 multi-year evaluation on the impact of the 

5 grants under subsections (b), (c), and (d), and 

6 to report to Congress and the Secretary on the 

7 findings of such evaluation. 

8 (B) EVALUATION.—The evaluation con9 ducted under this subsection shall— 

10 (i) be conducted in a manner con11 sistent with relevant, nationally recognized 

12 professional and technical evaluation 

13 standards; 

14 (ii) use sound statistical methods and 

15 techniques relating to the behavioral 

16 sciences, including quasi-experimental de17 signs, inferential statistics, and other 

18 methodologies and techniques that allow 

19 for conclusions to be reached; 

20 (iii) be carried out by an independent 

21 organization that has not received a grant 

22 under subsection (b), (c), or (d); and 

23 (iv) be designed to provide informa24 tion on— 


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1 (I) output measures, such as the 

2 number of individuals served under 

3 the grant and the number of hours of 

4 instruction; 

5 (II) outcome measures, including 

6 measures relating to— 

7 (aa) the knowledge that in8 dividuals participating in the 

9 grant program have gained in 

10 each of the following age and de11 velopmentally appropriate 

12 areas— 

13 (AA) growth and devel14 opment; 

15 (BB) relationship dy16 namics; 

17 (CC) ways to prevent 

18 unintended pregnancy and 

19 sexually transmitted infec20 tions, including HIV; and 

21 (DD) sexual health; 

22 (bb) the age and develop23 mentally appropriate skills that 

24 individuals participating in the 


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1 grant program have gained re2 garding— 

3 (AA) negotiation and 

4 communication; 

5 (BB) decisionmaking 

6 and goal-setting; 

7 (CC) interpersonal 

8 skills and healthy relation9 ships; and 

10 (DD) condom use; and 

11 (cc) the behaviors of adoles12 cents participating in the grant 

13 program, including data about— 

14 (AA) age of first inter15 course; 

16 (BB) condom and con17 traceptive use at first inter18 course; 

19 (CC) recent condom 

20 and contraceptive use; 

21 (DD) substance use; 

22 (EE) dating abuse and 

23 lifetime history of sexual as24 sault, dating violence, bulVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00406 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 lying, harassment, stalking; 

2 and 

3 (FF) academic per4 formance; and 

5 (III) other measures necessary to 

6 evaluate the impact of the grant pro7 gram. 

8 (C) REPORT.—Not later than 6 years after 

9 the date of enactment of this Act, the organiza10 tion conducting the evaluation under this sub11 section shall prepare and submit to the appro12 priate committees of Congress and the Sec13 retary an evaluation report. Such report shall 

14 be made publicly available, including on the 

15 website of the Department of Health and 

16 Human Services. 

17 (2) SECRETARY’S REPORT TO CONGRESS.—Not 

18 later than 1 year after the date of the enactment of 

19 this Act, and annually thereafter for a period of 5 

20 years, the Secretary shall prepare and submit to the 

21 appropriate committees of Congress a report on the 

22 activities to provide adolescents and young people 

23 with comprehensive sex education and pre-service 

24 and in-service teacher training funded under this 


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1 Act. The Secretary’s report to Congress shall in2 clude— 

3 (A) a statement of how grants awarded by 

4 the Secretary meet the purposes described in 

5 subsection (a)(1); and 

6 (B) information about— 

7 (i) the number of eligible entities and 

8 institutions of higher education that are 

9 receiving grant funds under subsections 

10 (b), (c), and (d); 

11 (ii) the specific activities supported by 

12 grant funds awarded under subsections 

13 (b), (c), and (d); 

14 (iii) the number of adolescents served 

15 by grant programs funded under sub16 section (b); 

17 (iv) the number of young people 

18 served by grant programs funded under 

19 subsection (c); 

20 (v) the number of faculty, school ad21 ministrators, teachers, and staff trained 

22 under subsection (d); and 

23 (vi) the status of the evaluation re24 quired under paragraph (1). 


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1 (f) NONDISCRIMINATION.—Programs funded under 

2 this Act shall not discriminate on the basis of actual or 

3 perceived sex, race, color, ethnicity, national origin, dis4 ability, sexual orientation, gender identity, or religion. 

5 Nothing in this Act shall be construed to invalidate or 

6 limit rights, remedies, procedures, or legal standards avail7 able under any other Federal law or any law of a State 

8 or a political subdivision of a State, including the Civil 

9 Rights Act of 1964 (42 U.S.C. 2000a et seq.), title IX 

10 of the Education Amendments of 1972 (20 U.S.C. 1681 

11 et seq.), section 504 of the Rehabilitation Act of 1973 (29 

12 U.S.C. 794), the Americans with Disabilities Act of 1990 

13 (42 U.S.C. 12101 et seq.), and section 1557 of the Patient 

14 Protection and Affordable Care Act (42 U.S.C. 18116). 

15 (g) LIMITATION.—No Federal funds provided under 

16 this Act may be used for health education programs 

17 that— 

18 (1) withhold health-promoting or life-saving in19 formation about sexuality-related topics, including 

20 HIV; 

21 (2) are medically inaccurate or have been sci22 entifically shown to be ineffective; 

23 (3) promote gender or racial stereotypes; 

24 (4) are insensitive and unresponsive to the 

25 needs of sexually active young people; 


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1 (5) are insensitive and unresponsive to the 

2 needs of pregnant or parenting young people; 

3 (6) are insensitive and unresponsive to the 

4 needs of survivors of sexual abuse or assault; 

5 (7) are insensitive and unresponsive to the 

6 needs of youth of all physical, developmental, or 

7 mental abilities; 

8 (8) are insensitive and unresponsive to individ9 uals with varying gender identities, gender expres10 sions, and sexual orientations; or 

11 (9) are inconsistent with the ethical imperatives 

12 of medicine and public health. 

13 (h) AMENDMENTS TO OTHER LAWS.— 

14 (1) AMENDMENT TO THE PUBLIC HEALTH

15 SERVICE ACT.—Section 2500 of the Public Health 

16 Service Act (42 U.S.C. 300ee) is amended by strik17 ing subsections (b) through (d) and inserting the fol18 lowing: 

19 ‘‘(b) CONTENTS OF PROGRAMS.—All programs of 

20 education and information receiving funds under this sub21 chapter shall include information about the potential ef22 fects of intravenous substance abuse.’’. 

23 (2) AMENDMENTS TO THE ELEMENTARY AND

24 SECONDARY EDUCATION ACT OF 1965.—Section 8526 


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1 of the Elementary and Secondary Education Act of 

2 (20 U.S.C. 7906) is amended— 

3 (A) by striking paragraph (3); 

4 (B) by redesignating paragraphs (4) and 

5 (5) as paragraphs (3) and (4), respectively; 

6 (C) in paragraph (4), by inserting ‘‘or’’ 

7 after the semicolon; 

8 (D) in paragraph (5), by striking ‘‘; or’’ 

9 and inserting a period; and 

10 (E) by striking paragraph (6). 

11 (i) DEFINITIONS.—In this section: 

12 (1) ADOLESCENTS.—The term ‘‘adolescents’’ 

13 means individuals who are ages 10 through 19 at 

14 the time of commencement of participation in a pro15 gram supported under this section. 

16 (2) AGE AND DEVELOPMENTALLY APPRO17 PRIATE.—The term ‘‘age and developmentally appro18 priate’’ means topics, messages, and teaching meth19 ods suitable to particular age, age group of children 

20 and adolescents, or developmental levels, based on 

21 cognitive, emotional, social, and behavioral capacity 

22 of most students at that age level. 

23 (3) APPROPRIATE COMMITTEES OF CON24 GRESS.—The term ‘‘appropriate committees of Con25 gress’’ means the Committee on Health, Education, 


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1 Labor, and Pensions of the Senate, the Committee 

2 on Appropriations of the Senate, the Committee on 

3 Energy and Commerce of the House of Representa4 tives, the Committee on Education and the Work5 force of the House of Representatives, and the Com6 mittee on Appropriations of the House of Represent7 atives. 

8 (4) CHARACTERISTICS OF EFFECTIVE PRO9 GRAMS.—The term ‘‘characteristics of effective pro10 grams’’ means the aspects of evidence-based pro11 grams, including development, content, and imple12 mentation of such programs, that— 

13 (A) have been shown to be effective in 

14 terms of increasing knowledge, clarifying values 

15 and attitudes, increasing skills, and impacting 

16 upon behavior; and 

17 (B) are widely recognized by leading med18 ical and public health agencies to be effective in 

19 changing sexual behaviors that lead to sexually 

20 transmitted infections, including HIV, unin21 tended pregnancy, and dating violence and sex22 ual assault among young people. 

23 (5) COMPREHENSIVE SEX EDUCATION.—The 

24 term ‘‘comprehensive sex education’’ means instruc25 tional part of a comprehensive school health eduVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00412 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 cation approach which addresses the physical, men2 tal, emotional, and social dimensions of human sexu3 ality; designed to motivate and assist students to 

4 maintain and improve their sexual health, prevent 

5 disease and reduce sexual health-related risk behav6 iors; and enable and empower students to develop 

7 and demonstrate age and developmentally appro8 priate sexuality and sexual health-related knowledge, 

9 attitudes, skills, and practices. 

10 (6) CONSENT.—The term ‘‘consent’’ means af11 firmative, conscious, and voluntary agreement to en12 gage in interpersonal, physical, or sexual activity. 

13 (7) CULTURALLY APPROPRIATE.—The term 

14 ‘‘culturally appropriate’’ means materials and in15 struction that respond to culturally diverse individ16 uals, families and communities in an inclusive, re17 spectful and effective manner; including materials 

18 and instruction that are inclusive of race, ethnicity, 

19 languages, cultural background, religion, sex, gender 

20 identity, sexual orientation, and different abilities. 

21 (8) EVIDENCE-BASED.—The term ‘‘evidence22 based’’, when used with respect to sex education in23 struction means a sex education program that has 

24 been proven through rigorous evaluation to be effec25 tive in changing sexual behavior or incorporates eleVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00413 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 ments of other programs that have been proven to 

2 be effective in changing sexual behavior. 

3 (9) GENDER EXPRESSION.—The term ‘‘gender 

4 expression’’, when used with respect to a sex edu5 cation program, means the expression of one’s gen6 der, such as through behavior, clothing, haircut, or 

7 voice, and which may or may not conform to socially 

8 defined behaviors and characteristics typically asso9 ciated with being either masculine or feminine. 

10 (10) GENDER IDENTITY.—Except with respect 

11 to section 7, the term ‘‘gender identity’’, when used 

12 with respect to a sex education program, means the 

13 gender-related identity, appearance, mannerisms, or 

14 other gender-related characteristics of an individual, 

15 regardless of the individual’s designated sex at birth 

16 including a person’s deeply held sense or knowledge 

17 of their own gender; such as male, female, both or 

18 neither. 

19 (11) INCLUSIVE.—The term ‘‘inclusive’’, when 

20 used with respect to a sex education program, means 

21 curriculum that ensures that students from histori22 cally marginalized communities are reflected in 

23 classroom materials and lessons. 

24 (12) INSTITUTION OF HIGHER EDUCATION.— 

25 The term ‘‘institution of higher education’’ has the 


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1 meaning given the term in section 101 of the Higher 

2 Education Act of 1965 (20 U.S.C. 1001). 

3 (13) MEDICALLY ACCURATE AND COMPLETE.— 

4 The term ‘‘medically accurate and complete’’, when 

5 used with respect to a sex education program, means 

6 that— 

7 (A) the information provided through the 

8 program is verified or supported by the weight 

9 of research conducted in compliance with ac10 cepted scientific methods and is published in 

11 peer-reviewed journals, where applicable; or 

12 (B)(i) the program contains information 

13 that leading professional organizations and 

14 agencies with relevant expertise in the field rec15 ognize as accurate, objective, and complete; and 

16 (ii) the program does not withhold infor17 mation about the effectiveness and benefits of 

18 correct and consistent use of condoms and 

19 other contraceptives. 

20 (14) SECRETARY.—The term ‘‘Secretary’’ 

21 means the Secretary of Health and Human Services. 

22 (15) SEXUAL DEVELOPMENT.—The term ‘‘sex23 ual development’’ means the lifelong process of phys24 ical, behavioral, cognitive, and emotional growth and 

25 change as it relates to an individual’s sexuality and 


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1 sexual maturation, including puberty, identity devel2 opment, socio-cultural influences, and sexual behav3 iors. 

4 (16) SEXUAL ORIENTATION.—Except with re5 spect to subsection (g), the term ‘‘sexual orienta6 tion’’, when used with respect to a sex education 

7 program, means an individual’s attraction, including 

8 physical or emotional, to the same or different gen9 der. 

10 (17) YOUNG PEOPLE.—The term ‘‘young peo11 ple’’ means individuals who are ages 10 through 24 

12 at the time of commencement of participation in a 

13 program supported under this Act. 

14 (j) FUNDING.— 

15 (1) APPROPRIATION.—For the purpose of car16 rying out this Act, there is appropriated 

17 $75,000,000 for each of fiscal years 2019 through 

18 2024. Amounts appropriated under this subsection 

19 shall remain available until expended. 

20 (2) RESERVATIONS OF FUNDS.— 

21 (A) The Secretary shall reserve 50 percent 

22 of the amount appropriated under paragraph 

23 (1) for the purposes of awarding grants for 

24 comprehensive sex education for adolescents 

25 under subsection (c). 


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1 (B) The Secretary shall reserve 25 percent 

2 of the amount appropriated under paragraph 

3 (1) for the purposes of awarding grants for 

4 comprehensive sex education at institutes of 

5 higher education under subsection (d). 

6 (C) The Secretary shall reserve 20 percent 

7 of the amount appropriated under paragraph 

8 (1) for the purposes of awarding grants for pre9 service and in-service teacher training under 

10 subsection (e). 

11 (D) The Secretary shall reserve 2 percent 

12 of the amount appropriated under paragraph 

13 (1) for the purpose of carrying out the impact 

14 evaluation and reporting required under sub15 section (a). 

16 (3) SECRETARIAL RESPONSIBILITIES.—The 

17 Secretary shall reserve 3 percent of the amount ap18 propriated under subsection (a) for each fiscal year 

19 for expenditures by the Secretary to provide, directly 

20 or through a competitive grant process, research, 

21 training, and technical assistance, including dissemi22 nation of research and information regarding effec23 tive and promising practices, providing consultation 

24 and resources, and developing resources and mate25 rials to support the activities of recipients of grants. 


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1 In carrying out such functions, the Secretary shall 

2 collaborate with a variety of entities that have exper3 tise in adolescent sexual health development, edu4 cation, and promotion. 

5 (4) REPROGRAMMING OF ABSTINENCE ONLY

6 UNTIL MARRIAGE PROGRAM FUNDING.—The unobli7 gated balance of funds made available to carry out 

8 section 510 of the Social Security Act (42 U.S.C. 

9 710) (as in effect on the day before the date of en10 actment of this Act) are hereby transferred and shall 

11 be used by the Secretary to carry out this Act. The 

12 amounts transferred and made available to carry out 

13 this Act shall remain available until expended. 

14 (5) REPEAL OF ABSTINENCE ONLY UNTIL MAR15 RIAGE PROGRAM.—Section 510 of the Social Secu16 rity Act (42 U.S.C. 710 et seq.) is repealed. 

17 SEC. 512. COMPASSIONATE ASSISTANCE FOR RAPE EMER18 GENCIES. 

19 (a) MEDICARE.— 

20 (1) LIMITATION ON PAYMENT.—Section 

21 1866(a)(1) of the Social Security Act (42 U.S.C. 

22 1395cc(a)(1)) is amended— 

23 (A) in the subparagraph (W) added by sec24 tion 3005(1)(C) of Public Law 111–148— 


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1 (i) by striking the period at the end 

2 and inserting a comma; 

3 (ii) by moving the indentation 2 ems 

4 to the left; and 

5 (iii) by moving such subparagraph to 

6 immediately follow subparagraph (V); 

7 (B) in the subparagraph (W) added by sec8 tion 6406(b)(3) of Public Law 111–148— 

9 (i) by striking the period at the end 

10 and inserting ‘‘, and’’; 

11 (ii) by moving the indentation 2 ems 

12 to the left; 

13 (iii) by redesignating such subpara14 graph as subparagraph (X); and 

15 (iv) by moving such subparagraph to 

16 immediately follow subparagraph (W), as 

17 moved under paragraph (2)(C); and 

18 (C) by inserting after the subparagraph 

19 (X), as redesignated and moved under para20 graph (3), the following: 

21 ‘‘(Y) in the case of a hospital or critical ac22 cess hospital, to adopt and enforce a policy to 

23 ensure compliance with the requirements of 

24 subsection (l) and to meet the requirements of 

25 such subsection.’’. 


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1 (2) ASSISTANCE TO VICTIMS.—Section 1866 of 

2 the Social Security Act (42 U.S.C. 1395cc) is 

3 amended by adding at the end the following new 

4 subsection: 

5 ‘‘(l) COMPASSIONATE ASSISTANCE FOR RAPE EMER6 GENCIES.— 

7 ‘‘(1) IN GENERAL.—For purposes of section 

8 1866(a)(1)(Y), a hospital meets the requirements of 

9 this subsection if the hospital provides each of the 

10 services described in paragraph (2) to each indi11 vidual, whether or not eligible for benefits under this 

12 title or under any other form of health insurance. 

13 who comes to the hospital on or after January 1, 

14 2019, and— 

15 ‘‘(A) who states to hospital personnel that 

16 they are victims of sexual assault; 

17 ‘‘(B) who is accompanied by an individual 

18 who states to hospital personnel that the indi19 vidual is a victim of sexual assault; or 

20 ‘‘(C) whom hospital personnel, during the 

21 course of treatment and care for the individual, 

22 have reason to believe is a victim of sexual as23 sault. 


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1 ‘‘(2) REQUIRED SERVICES DESCRIBED.—For 

2 purposes of paragraph (1), the services described in 

3 this subparagraph are the following: 

4 ‘‘(A) Provision of medically and factually 

5 accurate and unbiased written and oral infor6 mation about emergency contraception that— 

7 ‘‘(i) is written in clear and concise 

8 language; 

9 ‘‘(ii) is readily comprehensible; 

10 ‘‘(iii) includes an explanation that— 

11 ‘‘(I) emergency contraception has 

12 been approved by the Food and Drug 

13 Administration as an over-the-counter 

14 or prescription medication for individ15 uals, and is a safe and effective way 

16 to prevent pregnancy after unpro17 tected intercourse or contraceptive 

18 failure if taken in a timely manner; 

19 ‘‘(II) emergency contraception is 

20 more effective the sooner it is taken; 

21 and 

22 ‘‘(III) emergency contraception 

23 does not cause an abortion and cannot 

24 interrupt an established pregnancy; 


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1 ‘‘(iv) meets such conditions regarding 

2 the provision of such information in lan3 guages other than English as the Secretary 

4 may establish; and 

5 ‘‘(v) is provided without regard to the 

6 ability of the individual or their family to 

7 pay costs associated with the provision of 

8 such information to the individual. 

9 ‘‘(B) Immediate offer to provide emergency 

10 contraception to the individual at the hospital 

11 and, in the case that the individual accepts such 

12 offer, immediate provision to the individual of 

13 such contraception on the same day it is re14 quested without regard to the inability of the 

15 individual or their family to pay costs associ16 ated with the offer and provision of such con17 traception. 

18 ‘‘(C) Development and implementation of a 

19 written policy to ensure that an individual is 

20 present at the hospital, or on-call, who— 

21 ‘‘(i) has authority to dispense or pre22 scribe emergency contraception, independ23 ently, or under a protocol prepared by a 

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1 gency contraception at the hospital to a 

2 victim of sexual assault; and 

3 ‘‘(ii) is trained to comply with the re4 quirements of this section. 

5 ‘‘(D) Provision of medically and factually 

6 accurate and unbiased written and oral infor7 mation and counseling about post-exposure pro8 phylaxis (PEP) protocol for the prevention of 

9 HIV. 

10 ‘‘(E) Immediately offer to begin PEP to 

11 the individual at the hospital except in cases 

12 where the medical professional’s best judgement 

13 is that further evaluation is required or that 

14 such a regimen will be substantially detrimental 

15 to the individual’s health. Such provision shall 

16 be offered regardless of the individual’s ability 

17 to pay. Hospitals shall be responsible for ensur18 ing adequate supply of PEP medications to pro19 vide to patients. 

20 ‘‘(3) DEFINITIONS.—For purposes of this para21 graph: 

22 ‘‘(A) The term ‘emergency contraception’ 

23 means a drug or device (as such terms are de24 fined in section 201 of the Federal Food, Drug, 


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1 and Cosmetic Act (21 U.S.C. 321)) or a drug 

2 regimen that— 

3 ‘‘(i) is used postcoitally; 

4 ‘‘(ii) prevents pregnancy primarily by 

5 preventing or delaying ovulation, and does 

6 not terminate an established pregnancy; 

7 and 

8 ‘‘(iii) is approved by the Food and 

9 Drug Administration. 

10 ‘‘(B) The term ‘hospital’ includes a critical 

11 access hospital, as defined in section 

12 1861(mm)(1). 

13 ‘‘(C) The term ‘sexual assault’ means co14 itus in which the individual involved does not 

15 consent or lacks the legal capacity to consent.’’. 

16 (b) LIMITATION ON PAYMENT UNDER MEDICAID.— 

17 Section 1903(i) of the Social Security Act (42 U.S.C. 

18 1396b(i)) is amended by inserting after paragraph (11) 

19 the following new paragraph: 

20 ‘‘(12) with respect to any amount expended for 

21 care or services furnished under the plan by a hos22 pital on or after January 1, 2017, unless such hos23 pital meets the requirements specified in section 

24 1866(l) for purposes of title XVIII.’’. 


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1 SEC. 513. ACCESS TO BIRTH CONTROL DUTIES OF PHAR2 MACIES TO ENSURE PROVISION OF FDA-AP3 PROVED CONTRACEPTION. 

4 Part B of title II of the Public Health Service Act 

5 (42 U.S.C. 238 et seq.) is amended by adding at the end 

6 the following: 

7 ‘‘SEC. 249. DUTIES OF PHARMACIES TO ENSURE PROVISION 

8 OF FDA-APPROVED CONTRACEPTION. 

9 ‘‘(a) IN GENERAL.—Subject to subsection (c), a 

10 pharmacy that receives Food and Drug Administration11 approved drugs or devices in interstate commerce shall 

12 maintain compliance with the following: 

13 ‘‘(1) If a customer requests a contraceptive, in14 cluding emergency contraception, that is in stock, 

15 the pharmacy shall ensure that the contraceptive is 

16 provided to the customer— 

17 ‘‘(A) without delay; 

18 ‘‘(B) without regard to the customer’s age, 

19 gender, gender identity, or sexual orientation; 

20 ‘‘(C) without a requirement that identifica21 tion be presented; and 

22 ‘‘(D) despite any conflicts of employees to 

23 filling a prescription and dispensing a par24 ticular prescription drug or device due to sin25 cerely held moral, philosophical, or religious be26 liefs. 


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1 ‘‘(2) If a customer requests a contraceptive that 

2 is not in stock and the pharmacy in the normal 

3 course of business stocks contraception, the phar4 macy shall immediately inform the customer that the 

5 contraceptive is not in stock and without delay offer 

6 the customer the following options: 

7 ‘‘(A) If the customer prefers to obtain the 

8 contraceptive through a referral or transfer, the 

9 pharmacy shall— 

10 ‘‘(i) locate a pharmacy of the cus11 tomer’s choice or the closest pharmacy 

12 confirmed to have the contraceptive in 

13 stock; and 

14 ‘‘(ii) refer the customer or transfer 

15 the prescription to that pharmacy. 

16 ‘‘(B) If the customer prefers for the phar17 macy to order the contraceptive, the pharmacy 

18 shall obtain the contraceptive under the phar19 macy’s standard procedure for expedited order20 ing of medication and notify the customer when 

21 the contraceptive arrives. 

22 ‘‘(3) The pharmacy shall ensure that its em23 ployees do not— 


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1 ‘‘(A) intimidate, threaten, or harass cus2 tomers in the delivery of services relating to a 

3 request for contraception; 

4 ‘‘(B) interfere with or obstruct the delivery 

5 of services relating to a request for contracep6 tion; 

7 ‘‘(C) intentionally misrepresent or deceive 

8 customers about the availability of contracep9 tion or its mechanism of action; 

10 ‘‘(D) breach medical confidentiality with 

11 respect to a request for contraception or threat12 en to breach such confidentiality; or 

13 ‘‘(E) refuse to return a valid, lawful pre14 scription for contraception upon customer re15 quest. 

16 ‘‘(b) CONTRACEPTIVES NOT ORDINARILY

17 STOCKED.—Nothing in subsection (a)(2) shall be con18 strued to require any pharmacy to comply with such sub19 section if the pharmacy does not ordinarily stock contra20 ceptives in the normal course of business. 

21 ‘‘(c) REFUSALS PURSUANT TO STANDARD PHAR22 MACY PRACTICE.—This section does not prohibit a phar23 macy from refusing to provide a contraceptive to a cus24 tomer in accordance with any of the following: 


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1 ‘‘(1) If it is unlawful to dispense the contracep2 tive to the customer without a valid, lawful prescrip3 tion and no such prescription is presented. 

4 ‘‘(2) If the customer is unable to pay for the 

5 contraceptive. 

6 ‘‘(3) If the employee of the pharmacy refuses to 

7 provide the contraceptive on the basis of a profes8 sional clinical judgment. 

9 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec10 tion shall be construed to invalidate or limit rights, rem11 edies, procedures, or legal standards under title VII of the 

12 Civil Rights Act of 1964. 

13 ‘‘(e) PREEMPTION.—This section does not preempt 

14 any provision of State law or any professional obligation 

15 made applicable by a State board or other entity respon16 sible for licensing or discipline of pharmacies or phar17 macists, to the extent that such State law or professional 

18 obligation provides protections for customers that are 

19 greater than the protections provided by this section. 

20 ‘‘(f) ENFORCEMENT.— 

21 ‘‘(1) CIVIL PENALTY.—A pharmacy that vio22 lates a requirement of subsection (a) is liable to the 

23 United States for a civil penalty in an amount not 

24 exceeding $1,000 per day of violation, not to exceed 


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1 $100,000 for all violations adjudicated in a single 

2 proceeding. 

3 ‘‘(2) PRIVATE CAUSE OF ACTION.—Any person 

4 aggrieved as a result of a violation of a requirement 

5 of subsection (a) may, in any court of competent ju6 risdiction, commence a civil action against the phar7 macy involved to obtain appropriate relief, including 

8 actual and punitive damages, injunctive relief, and a 

9 reasonable attorney’s fee and cost. 

10 ‘‘(3) LIMITATIONS.—A civil action under para11 graph (1) or (2) may not be commenced against a 

12 pharmacy after the expiration of the 5-year period 

13 beginning on the date on which the pharmacy alleg14 edly engaged in the violation involved. 

15 ‘‘(g) DEFINITIONS.—In this section: 

16 ‘‘(1) The term ‘contraception’ or ‘contraceptive’ 

17 means any drug or device approved by the Food and 

18 Drug Administration to prevent pregnancy. 

19 ‘‘(2) The term ‘employee’ means a person hired, 

20 by contract or any other form of an agreement, by 

21 a pharmacy. 

22 ‘‘(3) The term ‘pharmacy’ means an entity 

23 that— 


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1 ‘‘(A) is authorized by a State to engage in 

2 the business of selling prescription drugs at re3 tail; and 

4 ‘‘(B) employs one or more employees. 

5 ‘‘(4) The term ‘product’ means a Food and 

6 Drug Administration-approved drug or device. 

7 ‘‘(5) The term ‘professional clinical judgment’ 

8 means the use of professional knowledge and skills 

9 to form a clinical judgment, in accordance with pre10 vailing medical standards. 

11 ‘‘(6) The term ‘without delay’, with respect to 

12 a pharmacy providing, providing a referral for, or 

13 ordering contraception, or transferring the prescrip14 tion for contraception, means within the usual and 

15 customary timeframe at the pharmacy for providing, 

16 providing a referral for, or ordering other products, 

17 or transferring the prescription for other products, 

18 respectively. 

19 ‘‘(h) EFFECTIVE DATE.—This section shall take ef20 fect on the 31st day after the date of the enactment of 

21 this section, without regard to whether the Secretary has 

22 issued any guidance or final rule regarding this section.’’. 


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1 SEC. 514. ADDITIONAL FOCUS AREA FOR THE OFFICE ON 

2 WOMEN’S HEALTH. 

3 Section 229(b) of the Public Health Service Act (42 

4 U.S.C. 237a(b)) is amended— 

5 (1) in paragraph (6), at the end, by striking 

6 ‘‘and’’; 

7 (2) in paragraph (7), at the end, by striking the 

8 period and inserting a semicolon; and 

9 (3) by adding at the end the following new 

10 paragraph: 

11 ‘‘(8) facilitate policymakers, health system lead12 ers and providers, consumers, and other stake13 holders in understanding optimal maternity care and 

14 support for the provision of such care, including the 

15 priorities of— 

16 ‘‘(A) protecting, promoting, and supporting 

17 the innate capacities of childbearing individuals 

18 and their newborns for childbirth, 

19 breastfeeding, and attachment; 

20 ‘‘(B) using obstetric interventions only 

21 when such interventions are supported by 

22 strong, high-quality evidence, and minimizing 

23 overuse of maternity practices that have been 

24 shown to have benefit in limited situations and 

25 that can expose women, infants, or both to risk 

26 of harm if used routinely and indiscriminately, 


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1 including continuous electronic fetal monitoring, 

2 labor induction, epidural analgesia, primary ce3 sarean section, and routine repeat cesarean 

4 birth; 

5 ‘‘(C) reliably incorporating noninvasive, 

6 evidence-based practices that have documented 

7 correlation with considerable improvement in 

8 outcomes with no detrimental side effects, such 

9 as smoking cessation programs in pregnancy 

10 and proven models of group prenatal care that 

11 integrate health assessment, education, and 

12 support into a unified program and supporting 

13 evidence-based breastfeeding promotion efforts 

14 with respect for a breastfeeding individual’s 

15 personal decisionmaking; 

16 ‘‘(D) a shared understanding of the quali17 fications of licensed providers of maternity care 

18 and the best evidence about the safety, satisfac19 tion, outcomes, and costs of their care, and ap20 propriate deployment of such caregivers within 

21 the maternity care workforce to address the 

22 needs of childbearing individuals and newborns 

23 and the growing shortage of maternity care24 givers; 


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1 ‘‘(E) a shared understanding of the results 

2 of the best available research comparing hos3 pital, birth center, and planned home births, in4 cluding information about each setting’s safety, 

5 satisfaction, outcomes, and costs; and 

6 ‘‘(F) high-quality, evidence-based child7 birth education that promotes a natural, 

8 healthy, and safe approach to pregnancy, child9 birth, and early parenting; is taught by certified 

10 educators, peer counselors, and health profes11 sionals; and promotes informed decisionmaking 

12 by childbearing individual;’’. 

13 SEC. 515. INTERAGENCY COORDINATING COMMITTEE ON 

14 THE PROMOTION OF OPTIMAL MATERNITY 

15 OUTCOMES. 

16 (a) IN GENERAL.—Part A of title II of the Public 

17 Health Service Act (42 U.S.C. 202 et seq.) is amended 

18 by adding at the end the following new section: 

19 ‘‘SEC. 229A. INTERAGENCY COORDINATING COMMITTEE ON 

20 THE PROMOTION OF OPTIMAL MATERNITY 

21 OUTCOMES. 

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

23 Human Services, acting through the Deputy Assistant 

24 Secretary for Women’s Health under section 229 and in 

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1 section (b), shall establish the Interagency Coordinating 

2 Committee on the Promotion of Optimal Maternity Out3 comes (referred to in this subsection as the ‘ICCPOM’). 

4 ‘‘(b) OTHER AGENCIES.—The officials specified in 

5 this subsection are the Secretary of Labor, the Secretary 

6 of Defense, the Secretary of Veterans Affairs, the Surgeon 

7 General, the Director of the Centers for Disease Control 

8 and Prevention, the Administrator of the Health Re9 sources and Services Agency, the Administrator of the 

10 Centers for Medicare & Medicaid Services, the Director 

11 of the Indian Health Service, the Administrator of the 

12 Substance Abuse and Mental Health Services Administra13 tion, the Director of the National Institute on Child 

14 Health and Development, the Director of the Agency for 

15 Healthcare Research and Quality, the Assistant Secretary 

16 for Children and Families, the Deputy Assistant Secretary 

17 for Minority Health, the Director of the Office of Per18 sonnel Management, and such other Federal officials as 

19 the Secretary of Health and Human Services determines 

20 to be appropriate. 

21 ‘‘(c) CHAIR.—The Deputy Assistant Secretary for 

22 Women’s Health shall serve as the chair of the ICCPOM. 

23 ‘‘(d) DUTIES.—The ICCPOM shall guide policy and 

24 program development across the Federal Government with 

25 respect to promotion of optimal maternity care, provided, 


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1 however, that nothing in this section shall be construed 

2 as transferring regulatory or program authority from an 

3 agency to the ICCPOM. 

4 ‘‘(e) CONSULTATIONS.—The ICCPOM shall actively 

5 seek the input of, and shall consult with, all appropriate 

6 and interested stakeholders, including State health depart7 ments, public health research and interest groups, founda8 tions, childbearing individuals and their advocates, and 

9 maternity care professional associations and organiza10 tions, reflecting racially, ethnically, demographically, and 

11 geographically diverse communities. 

12 ‘‘(f) ANNUAL REPORT.— 

13 ‘‘(1) IN GENERAL.—The Secretary, on behalf of 

14 the ICCPOM, shall annually submit to Congress a 

15 report that summarizes— 

16 ‘‘(A) all programs and policies of Federal 

17 agencies (including the Medicare Program 

18 under title XVIII of the Social Security Act and 

19 the Medicaid program under title XIX of such 

20 Act) designed to promote optimal maternity 

21 care, focusing particularly on programs and 

22 policies that support the adoption of evidence 

23 based maternity care, as defined by timely, sci24 entifically sound systematic reviews; 


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1 ‘‘(B) all programs and policies of Federal 

2 agencies (including the Medicare Program 

3 under title XVIII of the Social Security Act and 

4 the Medicaid program under title XIX of such 

5 Act) designed to address the problems of mater6 nal mortality and morbidity, infant mortality, 

7 prematurity, and low birth weight, including 

8 such programs and policies designed to address 

9 racial and ethnic disparities with respect to 

10 each of such problems; 

11 ‘‘(C) the extent of progress in reducing 

12 maternal mortality and infant mortality, low 

13 birth weight, and prematurity at State and na14 tional levels; and 

15 ‘‘(D) such other information regarding op16 timal maternity care as the Secretary deter17 mines to be appropriate. 

18 The information specified in subparagraph (C) shall 

19 be included in each such report in a manner that 

20 disaggregates such information by race, ethnicity, 

21 and indigenous status in order to determine the ex22 tent of progress in reducing racial and ethnic dis23 parities and disparities related to indigenous status. 

24 ‘‘(2) CERTAIN INFORMATION.—Each report 

25 under paragraph (1) shall include information 


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1 (disaggregated by race, ethnicity, and indigenous 

2 status, as applicable) on the following rates and 

3 costs by State: 

4 ‘‘(A) The rate of primary cesarean deliv5 eries and repeat cesarean deliveries. 

6 ‘‘(B) The rate of vaginal births after cesar7 ean. 

8 ‘‘(C) The rate of vaginal breech births. 

9 ‘‘(D) The rate of induction of labor. 

10 ‘‘(E) The rate of freestanding birth center 

11 births. 

12 ‘‘(F) The rate of planned and unplanned 

13 home birth. 

14 ‘‘(G) The rate of attended births by pro15 vider, including by an obstetrician-gynecologist, 

16 family practice physician, obstetrician-gyne17 cologist physician assistant, certified nurse-mid18 wife, certified midwife, and certified profes19 sional midwife. 

20 ‘‘(H) The cost of maternity care 

21 disaggregated by place of birth and provider of 

22 care, including— 

23 ‘‘(i) uncomplicated vaginal birth; 

24 ‘‘(ii) complicated vaginal birth; 


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1 ‘‘(iii) uncomplicated cesarean birth; 

2 and 

3 ‘‘(iv) complicated cesarean birth. 

4 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There 

5 is authorized to be appropriated, in addition to amounts 

6 authorized to be appropriated under section 229(e), to 

7 carry out this section $1,000,000 for each of the fiscal 

8 years 2019 through 2023.’’. 

9 (b) CONFORMING AMENDMENTS.— 

10 (1) INCLUSION AS DUTY OF HHS OFFICE ON

11 WOMEN’S HEALTH.—Section 229(b) of such Act (42 

12 U.S.C. 237a(b)), as amended by section 514, is fur13 ther amended by adding at the end the following 

14 new paragraph: 

15 ‘‘(9) establish the Interagency Coordinating 

16 Committee on the Promotion of Optimal Maternity 

17 Outcomes in accordance with section 229A; and’’. 

18 (2) TREATMENT OF BIENNIAL REPORTS.—Sec19 tion 229(d) of such Act (42 U.S.C. 237a(d)) is 

20 amended by inserting ‘‘(other than under subsection 

21 (b)(9))’’ after ‘‘under this section’’. 

22 SEC. 516. CONSUMER EDUCATION CAMPAIGN. 

23 Section 229(b) of the Public Health Service Act (42 

24 U.S.C. 237a(b)), as amended, is further amended by add25 ing at the end the following new paragraph: 


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1 ‘‘(10) not later than one year after the date of 

2 the enactment of the Health Equity and Account3 ability Act of 2018, develop and implement a 4-year 

4 culturally and linguistically appropriate multimedia 

5 consumer education campaign that is designed to 

6 promote understanding and acceptance of evidence7 based maternity practices and models of care for op8 timal maternity outcomes among individuals of 

9 childbearing ages and families of such individuals 

10 and that— 

11 ‘‘(A) highlights the importance of pro12 tecting, promoting, and supporting the innate 

13 capacities of childbearing individuals and their 

14 newborns for childbirth, breastfeeding, and at15 tachment; 

16 ‘‘(B) promotes understanding of the impor17 tance of using obstetric interventions when 

18 medically necessary and when supported by 

19 strong, high-quality evidence; 

20 ‘‘(C) highlights the widespread overuse of 

21 maternity practices that have been shown to 

22 have benefit when used appropriately in situa23 tions of medical necessity, but which can expose 

24 pregnant individuals, infants, or both to risk of 

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1 cluding continuous fetal monitoring, labor in2 duction, epidural anesthesia, elective primary 

3 cesarean section, and repeat cesarean delivery; 

4 ‘‘(D) emphasizes the noninvasive maternity 

5 practices that have strong proven correlation or 

6 may be associated with considerable improve7 ment in outcomes with no detrimental side ef8 fects, and are significantly underused in the 

9 United States, including smoking cessation pro10 grams in pregnancy, group model prenatal care, 

11 continuous labor support, nonsupine positions 

12 for birth, and external version to turn breech 

13 babies at term; 

14 ‘‘(E) educates consumers about the quali15 fications of licensed providers of maternity care 

16 and the best evidence about their safety, satis17 faction, outcomes, and costs; 

18 ‘‘(F) informs consumers about the best 

19 available research comparing birth center 

20 births, planned home births, and hospital 

21 births, including information about each set22 ting’s safety, satisfaction, outcomes, and costs; 

23 ‘‘(G) fosters participation in high-quality, 

24 evidence-based childbirth education that pro25 motes a natural, healthy, and safe approach to 


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1 pregnancy, childbirth, and early parenting; is 

2 taught by certified educators, peer counselors, 

3 and health professionals; and promotes in4 formed decisionmaking by childbearing individ5 uals; and 

6 ‘‘(H) is pilot tested for consumer com7 prehension, cultural sensitivity, and acceptance 

8 of the messages across geographically, racially, 

9 ethnically, and linguistically diverse popu10 lations.’’. 

11 SEC. 517. BIBLIOGRAPHIC DATABASE OF SYSTEMATIC RE12 VIEWS FOR CARE OF CHILDBEARING INDI13 VIDUALS AND NEWBORNS. 

14 (a) IN GENERAL.—Not later than one year after the 

15 date of the enactment of this Act, the Secretary of Health 

16 and Human Services, through the Agency for Healthcare 

17 Research and Quality, shall— 

18 (1) make publicly available an online biblio19 graphic database identifying systematic reviews, in20 cluding an explanation of the level and quality of 

21 evidence, for care of childbearing individuals and 

22 newborns; and 

23 (2) initiate regular updates that incorporate 

24 newly issued and updated systematic reviews. 


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1 (b) SOURCES.—To aim for a comprehensive inventory 

2 of systematic reviews relevant to maternal and newborn 

3 care, the database shall identify reviews from diverse 

4 sources, including— 

5 (1) scientific peer-reviewed journals; 

6 (2) databases, including Cochrane Database of 

7 Systematic Reviews, Clinical Evidence, and Data8 base of Abstracts of Reviews of Effects; and 

9 (3) Internet Web sites of agencies and organi10 zations throughout the world that produce such sys11 tematic reviews. 

12 (c) FEATURES.—The database shall— 

13 (1) provide bibliographic citations for each 

14 record within the database, and for each such cita15 tion include an explanation of the level and quality 

16 of evidence; 

17 (2) include abstracts, as available; 

18 (3) provide reference to companion documents 

19 as may exist for each review, such as evidence tables 

20 and guidelines or consumer educational materials de21 veloped from the review; 

22 (4) provide links to the source of the full review 

23 and to any companion documents; 

24 (5) provide links to the source of a previous 

25 version or update of the review; 


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1 (6) be searchable by intervention or other topic 

2 of the review, reported outcomes, author, title, and 

3 source; and 

4 (7) offer to users periodic electronic notification 

5 of database updates relating to users’ topics of inter6 est. 

7 (d) OUTREACH.—Not later than the first date the 

8 database is made publicly available and periodically there9 after, the Secretary of Health and Human Services shall 

10 publicize the availability, features, and uses of the data11 base under this section to the stakeholders described in 

12 subsection (e). 

13 (e) CONSULTATION.—For purposes of developing the 

14 database under this section and maintaining and updating 

15 such database, the Secretary of Health and Human Serv16 ices shall convene and consult with an advisory committee 

17 composed of relevant stakeholders, including— 

18 (1) Federal Medicaid administrators and State 

19 agencies administrating State plans under title XIX 

20 of the Social Security Act pursuant to section 

21 1902(a)(5) of such Act (42 U.S.C. 1396a(a)(5)); 

22 (2) providers of maternity and newborn care 

23 from both academic and community-based settings, 

24 including obstetrician-gynecologists, family physi25 cians, certified nurse midwives, certified midwives, 


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1 certified professional midwives, physician assistants, 

2 perinatal nurses, pediatricians, and nurse practi3 tioners; 

4 (3) maternal-fetal medicine specialists; 

5 (4) neonatologists; 

6 (5) childbearing individuals and advocates for 

7 such individuals, including childbirth educators cer8 tified by a nationally accredited program, rep9 resenting communities that are diverse in terms of 

10 race, ethnicity, indigenous status, and geographic 

11 area; 

12 (6) employers and purchasers; 

13 (7) health facility and system leaders, including 

14 both hospital and birth center facilities; 

15 (8) journalists; and 

16 (9) bibliographic informatics specialists. 

17 (f) AUTHORIZATION OF APPROPRIATIONS.—There is 

18 authorized to be appropriated $2,500,000 for each of the 

19 fiscal years 2019 through 2021 for the purpose of devel20 oping the database and such sums as may be necessary 

21 for each subsequent fiscal year for updating the database 

22 and providing outreach and notification to users, as de23 scribed in this section. 


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1 SEC. 518. MATERNITY CARE HEALTH PROFESSIONAL 

2 SHORTAGE AREAS. 

3 Section 332 of the Public Health Service Act (42 

4 U.S.C. 254e) is amended by adding at the end the fol5 lowing new subsection: 

6 ‘‘(k)(1) The Secretary, acting through the Adminis7 trator of the Health Resources and Services Administra8 tion, shall designate maternity care health professional 

9 shortage areas in the States, publish a descriptive list of 

10 the area’s population groups, medical facilities, and other 

11 public facilities so designated, and at least annually review 

12 and, as necessary, revise such designations. 

13 ‘‘(2) For purposes of paragraph (1), a complete de14 scriptive list shall be published in the Federal Register not 

15 later than one year after the date of the enactment of the 

16 Health Equity and Accountability Act of 2018 and annu17 ally thereafter. 

18 ‘‘(3) The provisions of subsections (b), (c), (e), (f), 

19 (g), (h), (i), and (j) (other than (j)(1)(B)) of this section 

20 shall apply to the designation of a maternity care health 

21 professional shortage area in a similar manner and extent 

22 as such provisions apply to the designation of health pro23 fessional shortage areas, except in applying subsection 

24 (b)(3), the reference in such subsection to ‘physicians’ 

25 shall be deemed to be a reference to nationally certified 

26 and State licensed obstetricians, family practice physicians 


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1 who practice full-scope maternity care, certified nurse 

2 midwives, certified midwives, certified professional mid3 wives, and physician’s assistants who practice full scope 

4 maternity care. 

5 ‘‘(4) For purposes of this subsection, the term ‘ma6 ternity care health professional shortage area’ means— 

7 ‘‘(A) an area in an urban or rural area (which 

8 need not conform to the geographic boundaries of a 

9 political subdivision and which is a rational area for 

10 the delivery of health services) which the Secretary 

11 determines has a shortage of providers of maternity 

12 care health services including those referenced in 

13 paragraph (3) or an urban or rural area that the 

14 Secretary determines has lost a significant number 

15 of such providers during the 10-year period begin16 ning with 2004 or has no obstetrical providers li17 censed to provide operative obstetrical services; 

18 ‘‘(B) an area in an urban or rural area (which 

19 need not conform to the geographic boundaries of a 

20 political subdivision and which is a rational area for 

21 the delivery of health services) which the Secretary 

22 determines has a shortage of hospital or labor and 

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1 cant number of these units during the 10-year pe2 riod beginning with 2004; or 

3 ‘‘(C) a population group which the Secretary 

4 determines has such a shortage of providers or fa5 cilities.’’. 

6 SEC. 519. EXPANSION OF CDC PREVENTION RESEARCH 

7 CENTERS PROGRAM TO INCLUDE CENTERS 

8 ON OPTIMAL MATERNITY OUTCOMES. 

9 (a) IN GENERAL.—Not later than one year after the 

10 date of the enactment of this Act, the Secretary of Health 

11 and Human Services, shall support the establishment of 

12 additional Prevention Research Centers under the Preven13 tion Research Center Program administered by the Cen14 ters for Disease Control and Prevention. Such additional 

15 centers shall each be known as a Center for Excellence 

16 on Optimal Maternity Outcomes. 

17 (b) RESEARCH.—Each Center for Excellence on Opti18 mal Maternity Outcomes shall— 

19 (1) conduct at least one focused program of re20 search to improve maternity outcomes, including the 

21 reduction of cesarean birth rates, elective inductions, 

22 prematurity rates, and low birth weight rates within 

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1 comes, including maternal mortality and morbidity, 

2 infant mortality, prematurity, or low birth weight; 

3 (2) work with partners on special interest 

4 projects, as specified by the Centers for Disease 

5 Control and Prevention and other relevant agencies 

6 within the Department of Health and Human Serv7 ices, and on projects funded by other sources; and 

8 (3) involve a minimum of two distinct birth set9 ting models, such as a hospital labor and delivery 

10 model and freestanding birth center model; or a hos11 pital labor and delivery model and planned home 

12 birth model. 

13 (c) INTERDISCIPLINARY PROVIDERS.—Each Center 

14 for Excellence on Optimal Maternity Outcomes shall in15 clude the following interdisciplinary providers of maternity 

16 care: 

17 (1) Obstetrician-gynecologists. 

18 (2) At least two of the following providers: 

19 (A) Family practice physicians. 

20 (B) Nurse practitioners. 

21 (C) Physician assistants. 

22 (D) Certified professional midwives. 

23 (d) SERVICES.—Research conducted by each Center 

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1 clude at least 2 (and preferably more) of the following sup2 portive provider services: 

3 (1) Mental health. 

4 (2) Doula labor support. 

5 (3) Nutrition education. 

6 (4) Childbirth education. 

7 (5) Social work. 

8 (6) Physical therapy or occupation therapy. 

9 (7) Substance abuse services. 

10 (8) Home visiting. 

11 (e) COORDINATION.—The programs of research at 

12 each of the two Centers of Excellence on Optimal Mater13 nity Outcomes shall compliment and not replicate the 

14 work of the other. 

15 (f) AUTHORIZATION OF APPROPRIATIONS.—There is 

16 authorized to be appropriated to carry out this section 

17 $2,000,000 for each of the fiscal years 2019 through 

18 2023. 

19 SEC. 520. EXPANDING MODELS ALLOWED TO BE TESTED BY 

20 CENTER FOR MEDICARE & MEDICAID INNO21 VATION TO INCLUDE MATERNITY CARE MOD22 ELS. 

23 Section 1115A(b)(2)(B) of the Social Security Act 

24 (42 U.S.C. 1315a(b)(2)(B)) is amended by adding at the 

25 end the following new clause: 


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1 ‘‘(xxv) Promoting evidence-based mod2 els of care that have been associated with 

3 reductions in maternal and infant health 

4 disparities, including incorporating the use 

5 of doula and promotoras support for preg6 nant and childbearing individuals into evi7 dence-based models of prenatal care, labor 

8 and delivery, and postpartum care, and 

9 supporting the appropriate use of out-of10 hospital birth models, including births at 

11 home and in freestanding birth centers.’’. 

12 SEC. 521. DEVELOPMENT OF INTERPROFESSIONAL MATER13 NITY CARE EDUCATIONAL MODELS AND 

14 TOOLS. 

15 (a) IN GENERAL.—Not later than 6 months after the 

16 date of the enactment of this Act, the Secretary of Health 

17 and Human Services, acting in conjunction with the Ad18 ministrator of Health Resources and Services Administra19 tion, shall convene, for a 1-year period, an Interprofes20 sional Maternity Provider Education Commission to dis21 cuss and make recommendations for— 

22 (1) a consensus standard physiologic maternity 

23 care curriculum that takes into account the core 

24 competencies for basic midwifery practice such as 

25 those developed by the American College of Nurse 


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1 Midwives and the North American Registry of Mid2 wives, and the educational objectives for physicians 

3 practicing in obstetrics and gynecology as deter4 mined by the Council on Resident Education in Ob5 stetrics and Gynecology; 

6 (2) suggestions for multidisciplinary use of the 

7 consensus physiologic curriculum; 

8 (3) strategies to integrate and coordinate edu9 cation across maternity care disciplines, including 

10 recommendations to increase medical and midwifery 

11 student exposure to out-of-hospital birth; and 

12 (4) pilot demonstrations of interprofessional 

13 educational models. 

14 (b) PARTICIPANTS.—The Commission shall include 

15 maternity care educators, curriculum developers, service 

16 leaders, certification leaders, and accreditation leaders 

17 from the various professions that provide maternity care 

18 in this country. Such professions shall include obstetrician 

19 gynecologists, certified nurse midwives or certified mid20 wives, family practice physicians, nurse practitioners, phy21 sician assistants, certified professional midwives, and 

22 perinatal nurses. Additionally, the Commission shall in23 clude representation from maternity care consumer advo24 cates. 


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1 (c) CURRICULUM.—The consensus standard physio2 logic maternity care curriculum described in subsection 

3 (a)(1) shall— 

4 (1) have a public health focus with a foundation 

5 in health promotion and disease prevention; 

6 (2) foster physiologic childbearing and woman 

7 and family centered care; 

8 (3) integrate strategies to reduce maternal and 

9 infant morbidity and mortality; 

10 (4) incorporate recommendations to ensure re11 spectful, safe, and seamless consultation, referral, 

12 transport, and transfer of care when necessary; and 

13 (5) include cultural sensitivity and strategies to 

14 decrease disparities in maternity outcomes. 

15 (d) REPORT.—Not later than 6 months after the final 

16 meeting of the Commission, the Secretary of Health and 

17 Human Services shall— 

18 (1) submit to Congress a report containing the 

19 recommendations made by the Commission under 

20 this section; and 

21 (2) make such report publicly available. 

22 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

23 authorized to be appropriated to carry out this section 

24 $1,000,000 for each of the fiscal years 2019 and 2020, 


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1 and such sums as are necessary for each of the fiscal years 

2 2021 through 2023. 

3 SEC. 522. INCLUDING WITHIN INPATIENT HOSPITAL SERV4 ICES UNDER MEDICARE SERVICES FUR5 NISHED BY CERTAIN STUDENTS, INTERNS, 

6 AND RESIDENTS SUPERVISED BY CERTIFIED 

7 NURSE MIDWIVES. 

8 (a) IN GENERAL.—Section 1861(b) of the Social Se9 curity Act (42 U.S.C. 1395x(b)) is amended— 

10 (1) in paragraph (6), by striking ‘‘; or’’ and in11 serting ‘‘, or in the case of services in a hospital or 

12 osteopathic hospital by a student midwife or an in13 tern or resident-in-training under a teaching pro14 gram previously described in this paragraph who is 

15 in the field of obstetrics and gynecology, if such stu16 dent midwife, intern, or resident-in-training is super17 vised by a certified nurse-midwife to the extent per18 mitted under applicable State law and as may be au19 thorized by the hospital;’’; 

20 (2) in paragraph (7), by striking the period at 

21 the end and inserting ‘‘; or’’; and 

22 (3) by adding at the end the following new 

23 paragraph: 


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1 ‘‘(8) a certified nurse-midwife where the hos2 pital has a teaching program approved as specified 

3 in paragraph (6), if— 

4 ‘‘(A) the hospital elects to receive any pay5 ment due under this title for reasonable costs of 

6 such services; and 

7 ‘‘(B) all certified nurse-midwives in such 

8 hospital agree not to bill charges for profes9 sional services rendered in such hospital to indi10 viduals covered under the insurance program 

11 established by this title.’’. 

12 (b) EFFECTIVE DATE.—The amendments made by 

13 subsection (a) shall apply to services furnished on or after 

14 the date of the enactment of this Act. 

15 SEC. 523. GRANTS TO PROFESSIONAL ORGANIZATIONS TO 

16 INCREASE DIVERSITY IN MATERNAL, REPRO17 DUCTIVE, AND SEXUAL HEALTH PROFES18 SIONALS. 

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

20 Human Services, through the Administrator of the Health 

21 Resources and Services Administration, shall carry out a 

22 grant program under which the Secretary may make to 

23 eligible health professional organizations— 

24 (1) for fiscal year 2019, planning grants de25 scribed in subsection (b); and 


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1 (2) for the subsequent 4-year period, implemen2 tation grants described in subsection (c). 

3 (b) PLANNING GRANTS.— 

4 (1) IN GENERAL.—Planning grants described in 

5 this subsection are grants for the following purposes: 

6 (A) To collect data and identify any work7 force disparities, with respect to a health pro8 fession, at each of the following areas along the 

9 health professional continuum: 

10 (i) Pipeline availability with respect to 

11 students at the high school and college or 

12 university levels considering and working 

13 toward entrance in the profession. 

14 (ii) Entrance into the training pro15 gram for the profession. 

16 (iii) Graduation from such training 

17 program. 

18 (iv) Entrance into practice. 

19 (v) Retention in practice for more 

20 than a 5-year period. 

21 (B) To develop one or more strategies to 

22 address the workforce disparities within the 

23 health profession, as identified under (and in 

24 response to the findings pursuant to) subpara25 graph (A). 


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1 (2) APPLICATION.—To be eligible to receive a 

2 grant under this subsection, an eligible health pro3 fessional organization shall submit to the Secretary 

4 of Health and Human Services an application in 

5 such form and manner and containing such informa6 tion as specified by the Secretary. 

7 (3) AMOUNT.—Each grant awarded under this 

8 subsection shall be for an amount not to exceed 

9 $300,000. 

10 (4) REPORT.—Each recipient of a grant under 

11 this subsection shall submit to the Secretary of 

12 Health and Human Services a report containing— 

13 (A) information on the extent and distribu14 tion of workforce disparities identified through 

15 the grant; and 

16 (B) reasonable objectives and strategies 

17 developed to address such disparities within a 

18 5-, 10-, and 25-year period. 

19 (c) IMPLEMENTATION GRANTS.— 

20 (1) IN GENERAL.—Implementation grants de21 scribed in this subsection are grants to implement 

22 one or more of the strategies developed pursuant to 

23 a planning grant awarded under subsection (b). 

24 (2) APPLICATION.—To be eligible to receive a 

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1 fessional organization shall submit to the Secretary 

2 of Health and Human Services an application in 

3 such form and manner as specified by the Secretary. 

4 Each such application shall contain information on 

5 the capability of the organization to carry out a 

6 strategy described in paragraph (1), involvement of 

7 partners or coalitions, plans for developing sustain8 ability of the efforts after the culmination of the 

9 grant cycle, and any other information specified by 

10 the Secretary. 

11 (3) AMOUNT.—Each grant awarded under this 

12 subsection shall be for an amount not to exceed 

13 $500,000 each year during the 4-year period of the 

14 grant. 

15 (4) REPORTS.—For each of the first 3 years for 

16 which an eligible health professional organization is 

17 awarded a grant under this subsection, the organiza18 tion shall submit to the Secretary of Health and 

19 Human Services a report on the activities carried 

20 out by such organization through the grant during 

21 such year and objectives for the subsequent year. 

22 For the fourth year for which an eligible health pro23 fessional organization is awarded a grant under this 

24 subsection, the organization shall submit to the Sec25 retary a report that includes an analysis of all the 


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1 activities carried out by the organization through the 

2 grant and a detailed plan for continuation of out3 reach efforts. 

4 (d) ELIGIBLE HEALTH PROFESSIONAL ORGANIZA5 TION DEFINED.—For purposes of this section, the term 

6 ‘‘eligible health professional organization’’ means a profes7 sional organization representing obstetrician-gyne8 cologists, certified nurse midwives, certified midwives, 

9 family practice physicians, nurse practitioners whose scope 

10 of practice includes maternity or sexual and reproductive 

11 health care, physician assistants whose scope of practice 

12 includes obstetrical or sexual and reproductive health care, 

13 or certified professional midwives adolescent medicine spe14 cialists, and pediatricians who provide sexual and repro15 ductive health care. 

16 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

17 authorized to be appropriated to carry out this section 

18 $2,000,000 for fiscal year 2019 and $3,000,000 for each 

19 of the fiscal years 2020 through 2023. 

20 SEC. 524. INTERAGENCY UPDATE TO THE QUALITY FAMILY 

21 PLANNING GUIDELINES. 

22 (a) IN GENERAL.—Not later than six months after 

23 the date of enactment of this Act, the Director of the Cen24 ters for Disease Control and Prevention and the Office 


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1 of Population Affairs shall review and expand the 2014 

2 Quality Family Planning Guidelines to address— 

3 (1) health disparities; and 

4 (2) the importance of patient-directed contra5 ceptive decisionmaking. 

6 (b) CONSULTATION.—In carrying out subsection (a), 

7 the Director of the Centers for Disease Control and Pre8 vention and the Office of Population Affairs shall convene 

9 a meeting, and solicit the views of, stakeholders including 

10 experts on health disparities, experts on reproductive coer11 cion, representatives of provider organizations, patient ad12 vocates, reproductive justice organizations, organizations 

13 that represent racial and ethnic minority communities, or14 ganizations that represent people with disabilities, organi15 zations that represent LGBTQ persons, and organizations 

16 that represent people with limited-English proficiency. 

17 SEC. 525. DISSEMINATION OF THE QUALITY FAMILY PLAN18 NING GUIDELINES. 

19 (a) IN GENERAL.—Not later than six months after 

20 the date of enactment of this Act, the Secretary of Health 

21 and Human Services and the Director of the Centers for 

22 Disease Control and Prevention shall— 

23 (1) develop a plan for outreach to publicly fund24 ed health care providers, including federally qualified 

25 health centers and branches of the Indian Health 


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1 Service, about the quality family planning guidelines 

2 referred to in section 524; and 

3 (2) award grants to eligible entities to imple4 ment these guidelines for all patients seeking family 

5 planning services. 

6 (b) DEFINITION.—In this section, the term ‘‘eligible 

7 entity’’ means a publicly funded health care provider that 

8 serves persons of reproductive age. 

9 Subtitle B—Pregnancy Screening 

10 SEC. 531. PREGNANCY INTENTION SCREENING INITIATIVE 

11 DEMONSTRATION PROGRAM. 

12 Part P of title III of the Public Health Service Act 

13 (42 U.S.C. 280g et seq.) is amended by adding at the end 

14 the following new sections: 

15 ‘‘SEC. 399V–7. PREGNANCY INTENTION SCREENING INITIA16 TIVE DEMONSTRATION PROGRAM. 

17 ‘‘(a) PROGRAM ESTABLISHMENT.—The Secretary, 

18 acting through the Director of the Centers for Disease 

19 Control and Prevention, shall establish a demonstration 

20 program to facilitate the clinical adoption of pregnancy in21 tention screening initiatives by health care providers. 

22 ‘‘(b) GRANTS.—The Secretary may carry out the 

23 demonstration program through awarding grants to eligi24 ble entities to implement pregnancy intention screening 

25 initiatives, collect data, and evaluate such initiatives. 


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1 ‘‘(c) ELIGIBLE ENTITIES.— 

2 ‘‘(1) IN GENERAL.—An eligible entity under 

3 this section is an entity described in paragraph (2) 

4 that provides non-directive, comprehensive, medically 

5 accurate information. 

6 ‘‘(2) ENTITIES DESCRIBED.—For purposes of 

7 paragraph (1), an entity described in this paragraph 

8 is a community-based organization, voluntary health 

9 organization, public health department, community 

10 health center, or other interested public or private 

11 health care provider or organization. 

12 ‘‘(d) PREGNANCY INTENTION SCREENING INITIA13 TIVE.—For purposes of this section, the term ‘pregnancy 

14 intention screening initiative’ means any initiative by a 

15 health care provider to routinely screen women with re16 spect to their pregnancy intentions and goals to either pre17 vent unintended pregnancies or improve the likelihood of 

18 healthy pregnancies, in order to better provide health care 

19 that meets the contraceptive or pre-pregnancy needs of 

20 such women. 

21 ‘‘(e) EVALUATION.— 

22 ‘‘(1) IN GENERAL.—The Secretary, acting 

23 through the Director of the Centers for Disease 

24 Control and Prevention, shall, by grant or contract, 

25 and after consultation as described in paragraph (2), 


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1 conduct an evaluation of the demonstration pro2 gram, with respect to pregnancy intention screening 

3 initiatives, conducted under this section. The evalua4 tion shall include: 

5 ‘‘(A) Assessment of the implementation of 

6 pregnancy intention screening protocols among 

7 a diverse group of patients and providers, in8 cluding collecting data on the experiences and 

9 outcomes for diverse patient populations in a 

10 variety of clinical settings. 

11 ‘‘(B) Analysis of outcome measures that 

12 will facilitate effective and widespread adoption 

13 of such protocols by health care providers for 

14 inquiring about and responding to pregnancy 

15 intentions of women with both contraceptive 

16 and pre-pregnancy care. 

17 ‘‘(C) Consideration of health disparities 

18 among the population served. 

19 ‘‘(D) Assessment of the equitable and vol20 untary application of such initiatives to minor21 ity and medically underserved communities. 

22 ‘‘(E) Assessment of the training, capacity, 

23 and ongoing technical assistance needed for 

24 providers to effectively implement such preg25 nancy intention screening protocols. 


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1 ‘‘(F) Assessment of whether referral sys2 tems for selected protocols follow evidence-based 

3 standards that ensure access to comprehensive 

4 health services and appropriate follow-up care. 

5 ‘‘(2) INDEPENDENT, EXPERT ADVISORY

6 PANEL.—In conducting the evaluation under para7 graph (1), the Director of the Centers for Disease 

8 Control and Prevention shall consult with physi9 cians, physician assistants, and nurses who spe10 cialize in women’s health, and other experts in clin11 ical practice, program evaluation, and research. 

12 ‘‘(3) REPORT.—Not later than one year after 

13 the last day of the demonstration program under 

14 this section, the Director of the Centers for Disease 

15 Control and Prevention shall submit to Congress a 

16 report on the results of the evaluation conducted 

17 under paragraph (1) and shall make the report pub18 licly available. 

19 ‘‘(f) FUNDING.— 

20 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

21 To carry out this section, there is authorized to be 

22 appropriated $5,000,000 for each of fiscal years 

23 2019 through 2021. 

24 ‘‘(2) LIMITATION.—Not more than 25 percent 

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1 suant to paragraph (1) for a fiscal year may be used 

2 for purposes of the evaluation under subsection 

3 (e).’’. 

4 TITLE VI—MENTAL HEALTH 

5 SEC. 601. MENTAL HEALTH FINDINGS. 

6 Congress finds the following: 

7 (1) Despite the existence of effective treat8 ments, disparities lie in the availability, accessibility, 

9 and quality of mental health services for racial and 

10 ethnic minorities. 

11 (2) These disparities have powerful significance 

12 for minority groups and for society as a whole. 

13 (3) Racial and ethnic minorities bear a greater 

14 burden from unmet mental health needs and thus 

15 suffer a greater loss to their overall health and pro16 ductivity. 

17 (4) The foremost barriers include the cost of 

18 care, societal stigma, and the fragmented organiza19 tion of services. 

20 (5) African American attitudes toward mental 

21 illness are another barrier to seeking mental health 

22 care. 

23 (6) Mental illness retains considerable stigma, 

24 and seeking treatment is not always encouraged. 


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1 (7) Mental illness is highly stigmatizing in 

2 many Asian cultures. 

3 (8) Addressing mental health stigma in commu4 nities will help increase utilization of mental health 

5 services and reduce the burden of mental illness 

6 SEC. 602. COVERAGE OF MARRIAGE AND FAMILY THERA7 PIST SERVICES, MENTAL HEALTH COUN8 SELOR SERVICES, AND SUBSTANCE ABUSE 

9 COUNSELOR SERVICES UNDER PART B OF 

10 THE MEDICARE PROGRAM. 

11 (a) COVERAGE OF SERVICES.— 

12 (1) IN GENERAL.—Section 1861(s)(2) of the 

13 Social Security Act (42 U.S.C. 1395x(s)(2)), as 

14 amended by section 450, is amended— 

15 (A) in subparagraph (FF), by striking 

16 ‘‘and’’ at the end; 

17 (B) in subparagraph (GG), by inserting 

18 ‘‘and’’ at the end; and 

19 (C) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(HH) marriage and family therapist services 

22 (as defined in subsection (lll)(1)) and mental health 

23 counselor services (as defined in subsection (lll)(3)) 

24 and substance abuse counselor services (as defined 

25 in subsection (lll)(5));’’. 


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1 (2) DEFINITIONS.—Section 1861 of such Act 

2 (42 U.S.C. 1395x), as amended by sections 413(a) 

3 and 470(a), is amended by adding at the end the 

4 following new subsection: 

5 ‘‘Marriage and Family Therapist Services; Marriage and 

6 Family Therapist; Mental Health Counselor Serv7 ices; Mental Health Counselor 

8 ‘‘(lll)(1) The term ‘marriage and family therapist 

9 services’ means services performed by a marriage and 

10 family therapist (as defined in paragraph (2)) for the diag11 nosis and treatment of mental illnesses, which the mar12 riage and family therapist is legally authorized to perform 

13 under State law (or the State regulatory mechanism pro14 vided by State law) of the State in which such services 

15 are performed, as would otherwise be covered if furnished 

16 by a physician or as an incident to a physician’s profes17 sional service, but only if no facility or other provider 

18 charges or is paid any amounts with respect to the fur19 nishing of such services. 

20 ‘‘(2) The term ‘marriage and family therapist’ means 

21 an individual who— 

22 ‘‘(A) possesses a master’s or doctoral degree 

23 which qualifies for licensure or certification as a 

24 marriage and family therapist pursuant to State 

25 law; 


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1 ‘‘(B) after obtaining such degree has performed 

2 at least 2 years of clinical supervised experience in 

3 marriage and family therapy; and 

4 ‘‘(C) in the case of an individual performing 

5 services in a State that provides for licensure or cer6 tification of marriage and family therapists, is li7 censed or certified as a marriage and family thera8 pist in such State. 

9 ‘‘(3) The term ‘mental health counselor services’ 

10 means services performed by a mental health counselor (as 

11 defined in paragraph (4)) for the diagnosis and treatment 

12 of mental illnesses which the mental health counselor is 

13 legally authorized to perform under State law (or the 

14 State regulatory mechanism provided by the State law) of 

15 the State in which such services are performed, as would 

16 otherwise be covered if furnished by a physician or as inci17 dent to a physician’s professional service, but only if no 

18 facility or other provider charges or is paid any amounts 

19 with respect to the furnishing of such services. 

20 ‘‘(4) The term ‘mental health counselor’ means an 

21 individual who— 

22 ‘‘(A) possesses a master’s or doctor’s degree in 

23 mental health counseling or a related field; 


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1 ‘‘(B) after obtaining such a degree has per2 formed at least 2 years of supervised mental health 

3 counselor practice; and 

4 ‘‘(C) in the case of an individual performing 

5 services in a State that provides for licensure or cer6 tification of mental health counselors or professional 

7 counselors, is licensed or certified as a mental health 

8 counselor or professional counselor in such State. 

9 ‘‘(5) The term ‘substance abuse counselor services’ 

10 means services performed by a substance abuse counselor 

11 (as defined in paragraph (6)) for the diagnosis and treat12 ment of substance abuse and addiction which the sub13 stance abuse counselor is legally authorized to perform 

14 under State law (or the State regulatory mechanism pro15 vided by the State law) of the State in which such services 

16 are performed, as would otherwise be covered if furnished 

17 by a physician or as incident to a physician’s professional 

18 service, but only if no facility or other provider charges 

19 or is paid any amounts with respect to the furnishing of 

20 such services. 

21 ‘‘(6) The term ‘substance abuse counselor’ means an 

22 individual who— 

23 ‘‘(A) has performed at least 2 years of super24 vised substance abuse counselor practice; 


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1 ‘‘(B) in the case of an individual performing 

2 services in a State that provides for licensure or cer3 tification of substance abuse counselors or profes4 sional counselors, is licensed or certified as a sub5 stance abuse counselor or professional counselor in 

6 such State; or 

7 ‘‘(C) is a drug and alcohol counselor as defined 

8 in section 40.281 of title 49, Code of Federal Regu9 lations.’’. 

10 (3) PROVISION FOR PAYMENT UNDER PART

11 B.—Section 1832(a)(2)(B) of such Act (42 U.S.C. 

12 1395k(a)(2)(B)) is amended— 

13 (A) by striking ‘‘and’’ at the end of clause 

14 (iv); and 

15 (B) by adding at the end the following new 

16 clause: 

17 ‘‘(v) marriage and family therapist 

18 services, mental health counselor services, 

19 and substance abuse counselor services; 

20 and’’. 

21 (4) AMOUNT OF PAYMENT.—Section 1833(a)(1) 

22 of such Act (42 U.S.C. 1395l(a)(1)), as amended by 

23 section 431(c)(3), is amended— 

24 (A) by striking ‘‘and (AA)’’ and inserting 

25 ‘‘(AA)’’; and 


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1 (B) by inserting before the semicolon at 

2 the end the following: ‘‘, and (BB) with respect 

3 to marriage and family therapist services, men4 tal health counselor services, and substance 

5 abuse counselor services under section 

6 1861(s)(2)(HH), the amounts paid shall be 80 

7 percent of the lesser of the actual charge for 

8 the services or 75 percent of the amount deter9 mined for payment of a psychologist under sub10 paragraph (L)’’. 

11 (5) EXCLUSION OF MARRIAGE AND FAMILY

12 THERAPIST SERVICES AND MENTAL HEALTH COUN13 SELOR SERVICES FROM SKILLED NURSING FACILITY

14 PROSPECTIVE PAYMENT SYSTEM.—Section 

15 1888(e)(2)(A)(ii) of such Act (42 U.S.C. 

16 1395yy(e)(2)(A)(ii)) is amended by inserting ‘‘mar17 riage and family therapist services (as defined in 

18 section 1861(lll)(1)), mental health counselor serv19 ices (as defined in section 1861(lll)(3)),’’ after 

20 ‘‘qualified psychologist services,’’. 

21 (6) INCLUSION OF MARRIAGE AND FAMILY

22 THERAPISTS, MENTAL HEALTH COUNSELORS, AND

23 SUBSTANCE ABUSE COUNSELORS AS PRACTITIONERS

24 FOR ASSIGNMENT OF CLAIMS.—Section 

25 1842(b)(18)(C) of such Act (42 U.S.C. 


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1 1395u(b)(18)(C)) is amended by adding at the end 

2 the following new clauses: 

3 ‘‘(vii) A marriage and family therapist (as de4 fined in section 1861(lll)(2)). 

5 ‘‘(viii) A mental health counselor (as defined in 

6 section 1861(lll)(4)). 

7 ‘‘(ix) A substance abuse counselor (as defined 

8 in section 1861 (lll)(6)).’’. 

9 (b) COVERAGE OF CERTAIN MENTAL HEALTH SERV10 ICES PROVIDED IN CERTAIN SETTINGS.— 

11 (1) RURAL HEALTH CLINICS AND FEDERALLY

12 QUALIFIED HEALTH CENTERS.—Section 

13 1861(aa)(1)(B) of the Social Security Act (42 

14 U.S.C. 1395x(aa)(1)(B)) is amended by striking ‘‘or 

15 by a clinical social worker (as defined in subsection 

16 (hh)(1)),’’ and inserting ‘‘, by a clinical social worker 

17 (as defined in subsection (hh)(1)), by a marriage 

18 and family therapist (as defined in subsection 

19 (lll)(2)), or by a mental health counselor (as defined 

20 in subsection (lll)(4)), or by a substance abuse coun21 selor (as defined in section 1861 (lll)(6)).’’. 

22 (2) HOSPICE PROGRAMS.—Section 

23 1861(dd)(2)(B)(i)(III) of such Act (42 U.S.C. 

24 1395x(dd)(2)(B)(i)(III)) is amended by inserting ‘‘or 


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1 one marriage and family therapist (as defined in 

2 subsection (lll)(2))’’ after ‘‘social worker’’. 

3 (c) AUTHORIZATION OF MARRIAGE AND FAMILY

4 THERAPISTS TO DEVELOP DISCHARGE PLANS FOR

5 POSTHOSPITAL SERVICES.—Section 1861(ee)(2)(G) of 

6 the Social Security Act (42 U.S.C. 1395x(ee)(2)(G)) is 

7 amended by inserting ‘‘marriage and family therapist (as 

8 defined in subsection (lll)(2)),’’ after ‘‘social worker,’’. 

9 (d) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply with respect to services furnished 

11 on or after January 1, 2019. 

12 SEC. 603. INTEGRATED HEALTH CARE DEMONSTRATION 

13 PROGRAM. 

14 Part D of title V of the Public Health Service Act 

15 (42 U.S.C. 290dd et seq.) is amended by adding at the 

16 end the following: 

17 ‘‘SEC. 550. INTERPROFESSIONAL HEALTH CARE TEAMS FOR 

18 PROVISION OF BEHAVIORAL HEALTH CARE 

19 IN PRIMARY CARE SETTINGS. 

20 ‘‘(a) GRANTS.—The Secretary, acting through the 

21 Assistant Secretary for Mental Health and Substance 

22 Abuse, shall award grants to eligible entities for the pur23 pose of establishing interprofessional health care teams 

24 that provide behavioral health care. 


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1 ‘‘(b) ELIGIBLE ENTITIES.—To be eligible to receive 

2 a grant under this section, an entity shall be a federally 

3 qualified health center (as defined in section 1861(aa) of 

4 the Social Security Act), rural health clinic, or behavioral 

5 health program, serving a high proportion of individuals 

6 from racial and ethnic minority groups (as defined in sec7 tion 1707(g)). 

8 ‘‘(c) SCIENTIFICALLY BASED.—Integrated health 

9 care funded through this section shall be scientifically 

10 based, taking into consideration the results of the most 

11 recent peer-reviewed research available. 

12 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—To 

13 carry out this section, there is authorized to be appro14 priated $20,000,000 for each of fiscal years 2019 through 

15 2024.’’. 

16 SEC. 604. ADDRESSING RACIAL AND ETHNIC MINORITY 

17 MENTAL HEALTH DISPARITIES RESEARCH 

18 GAPS. 

19 Not later than 6 months after the date of the enact20 ment of this Act, the Director of the National Institute 

21 on Minority Health and Health Disparities shall enter into 

22 an arrangement with the National Academy of Sciences 

23 (or, if the National Academy of Sciences declines to enter 

24 into such an arrangement, an arrangement with the Insti25 tute of Medicine, the Patient Centered Outcomes Research 


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1 Institute, the Agency for Healthcare Quality, or another 

2 appropriate entity)— 

3 (1) to conduct a study with respect to mental 

4 health disparities in racial and ethnic minority 

5 groups (as defined in section 1707(g) of the Public 

6 Health Service Act (42 U.S.C. 300u–6(g)); and 

7 (2) to submit to the Congress a report on the 

8 results of such study, including— 

9 (A) a compilation of information on the dy10 namics of mental disorders in such racial and 

11 ethnic minority groups; and 

12 (B) a compilation of information on the 

13 impact of exposure to community violence, ad14 verse childhood experiences, and other psycho15 logical traumas on mental disorders in such ra16 cial and minority groups. 

17 SEC. 605. HEALTH PROFESSIONS COMPETENCIES TO AD18 DRESS RACIAL AND ETHNIC MINORITY MEN19 TAL HEALTH DISPARITIES. 

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

21 Human Services, acting through the Assistant Secretary 

22 for Mental Health and Substance Use, shall award grants 

23 to qualified national organizations for the purposes of— 

24 (1) developing, and disseminating to health pro25 fessional educational programs curricula or core 


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1 competencies addressing mental health disparities 

2 among racial and ethnic minority groups for use in 

3 the training of students in the professions of social 

4 work, psychology, psychiatry, marriage and family 

5 therapy, mental health counseling, and substance 

6 abuse counseling; and 

7 (2) certifying community health workers and 

8 peer wellness specialists with respect to such cur9 ricula and core competencies and integrating and ex10 panding the use of such workers and specialists into 

11 health care to address mental health disparities 

12 among racial and ethnic minority groups. 

13 (b) CURRICULA; CORE COMPETENCIES.—Organiza14 tions receiving funds under subsection (a) may use the 

15 funds to engage in the following activities related to the 

16 development and dissemination of curricula or core com17 petencies described in subsection (a)(1): 

18 (1) Formation of committees or working groups 

19 comprised of experts from accredited health profes20 sions schools to identify core competencies relating 

21 to mental health disparities among racial and ethnic 

22 minority groups. 

23 (2) Planning of workshops in national fora to 

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1 sociated with mental health disparities among racial 

2 and ethnic minority groups. 

3 (3) Dissemination and promotion of the use of 

4 curricula or core competencies in undergraduate and 

5 graduate health professions training programs na6 tionwide. 

7 (4) Establishing external stakeholder advisory 

8 boards to provide meaningful input into policy and 

9 program development and best practices to reduce 

10 mental health disparities among racial and ethnic 

11 minority groups. 

12 (c) DEFINITIONS.—In this section: 

13 (1) QUALIFIED NATIONAL ORGANIZATION.—The 

14 term ‘‘qualified national organization’’ means a na15 tional organization that focuses on the education of 

16 students in programs of social work, psychology, 

17 psychiatry, and marriage and family therapy. 

18 (2) RACIAL AND ETHNIC MINORITY GROUP.— 

19 The term ‘‘racial and ethnic minority group’’ has the 

20 meaning given to such term in section 1707(g) of 

21 the Public Health Service Act (42 U.S.C. 300u– 

22 6(g)). 

23 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

24 are authorized to be appropriated to carry out this section 


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1 such sums as may be necessary for each of fiscal years 

2 2019 through 2024. 

3 SEC. 606. ASIAN AMERICAN, NATIVE HAWAIIAN, AND PA4 CIFIC ISLANDER BEHAVIORAL AND MENTAL 

5 HEALTH OUTREACH AND EDUCATION STRAT6 EGIES. 

7 Part D of title V of the Public Health Service Act 

8 (42 U.S.C. 290dd et seq.) is amended by adding at the 

9 end the following new section: 

10 ‘‘SEC. 544. BEHAVIORAL AND MENTAL HEALTH OUTREACH 

11 AND EDUCATION STRATEGIES. 

12 ‘‘(a) IN GENERAL.—The Secretary, acting through 

13 the Administrator of the Substance Abuse and Mental 

14 Health Services Administration, shall, in coordination with 

15 advocacy and behavioral and mental health organizations 

16 serving populations of Asian American, Native Hawaiian, 

17 and Pacific Islander individuals or communities, develop 

18 and implement an outreach and education strategy to pro19 mote behavioral and mental health and reduce stigma as20 sociated with mental health conditions and substance 

21 abuse among the Asian American, Native Hawaiian, and 

22 Pacific Islander populations. Such strategy shall— 

23 ‘‘(1) be designed to— 

24 ‘‘(A) meet the diverse cultural and lan25 guage needs of the various Asian American, 


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1 Native Hawaiian, and Pacific Islander popu2 lations; and 

3 ‘‘(B) ensure such strategies are develop4 mentally and age appropriate; 

5 ‘‘(2) increase awareness of symptoms of mental 

6 illnesses common among such populations, taking 

7 into account differences within subgroups, such as 

8 gender, gender identity, age, sexual orientation, or 

9 ethnicity, of such populations; 

10 ‘‘(3) provide information on evidence-based, cul11 turally and linguistically appropriate and adapted 

12 interventions and treatments; 

13 ‘‘(4) ensure full participation of, and engage, 

14 both consumers and community members in the de15 velopment and implementation of materials; and 

16 ‘‘(5) seek to broaden the perspective among 

17 both individuals in these communities and stake18 holders serving these communities to use a com19 prehensive public health approach to promoting be20 havioral health that addresses a holistic view of 

21 health by focusing on the intersection between be22 havioral and physical health. 

23 ‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—There 

24 is authorized to be appropriated to carry out this section 

25 $300,000 for fiscal year 2019.’’. 


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1 SEC. 607. MENTAL HEALTH IN SCHOOLS. 

2 (a) PURPOSE.—It is the purpose of this section to— 

3 (1) revise, increase funding for, and expand the 

4 scope of the Project AWARE State Educational 

5 Agency Grant Program carried out by the Secretary 

6 of Health and Human Services, in order to provide 

7 access to more comprehensive school-based mental 

8 health services and supports; 

9 (2) provide for comprehensive staff development 

10 for school and community service personnel working 

11 in the school; and 

12 (3) provide for comprehensive training for chil13 dren with mental health disorders, for parents, sib14 lings, and other family members of such children, 

15 and for concerned members of the community. 

16 (b) TECHNICAL AMENDMENTS.—The second part G 

17 (relating to services provided through religious organiza18 tions) of title V of the Public Health Service Act (42 

19 U.S.C. 290kk et seq.) is amended— 

20 (1) by redesignating such part as part J; and 

21 (2) by redesignating sections 581 through 584 

22 as sections 596 through 596C, respectively. 

23 (c) SCHOOL-BASED MENTAL HEALTH AND CHIL24 DREN AND VIOLENCE.—Section 581 of the Public Health 

25 Service Act (42 U.S.C. 290hh) is amended to read as fol26 lows: 


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1 ‘‘SEC. 581. SCHOOL-BASED MENTAL HEALTH AND CHIL2 DREN AND VIOLENCE. 

3 ‘‘(a) IN GENERAL.—The Secretary, in collaboration 

4 with the Secretary of Education and in consultation with 

5 the Attorney General, shall, directly or through grants, 

6 contracts, or cooperative agreements awarded to eligible 

7 entities described in subsection (c), assist local commu8 nities and schools (including schools funded by the Bureau 

9 of Indian Education) in applying a public health approach 

10 to mental health services both in schools and in the com11 munity. Such approach should provide comprehensive age 

12 appropriate services and supports, be linguistically and 

13 culturally appropriate, be trauma-informed, and incor14 porate age appropriate strategies of positive behavioral 

15 interventions and supports. A comprehensive school men16 tal health program funded under this section shall assist 

17 children in dealing with trauma and violence. 

18 ‘‘(b) ACTIVITIES.—Under the program under sub19 section (a), the Secretary may— 

20 ‘‘(1) provide financial support to enable local 

21 communities to implement a comprehensive cul22 turally and linguistically appropriate, trauma-in23 formed, and age-appropriate, school-based mental 

24 health program that— 

25 ‘‘(A) builds awareness of trauma; 


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1 ‘‘(B) trains appropriate staff to identify 

2 signs of trauma or mental health disorders; and 

3 ‘‘(C) incorporates positive behavioral inter4 ventions, family engagement, student treatment, 

5 and multi-generational supports to foster the 

6 health and development of children; 

7 ‘‘(2) provide technical assistance to local com8 munities with respect to the development of pro9 grams described in paragraph (1); 

10 ‘‘(3) provide assistance to local communities in 

11 the development of policies to address child and ado12 lescent trauma and mental health issues and violence 

13 when and if it occurs; 

14 ‘‘(4) facilitate community partnerships among 

15 families, students, law enforcement agencies, edu16 cation systems, mental health and substance use dis17 order service systems, family-based mental health 

18 service systems, child welfare agencies, health care 

19 service systems (including primary care physicians), 

20 faith-based programs, trauma networks, and other 

21 community-based systems; and 

22 ‘‘(5) establish mechanisms for children and ado23 lescents to report incidents of violence or plans by 

24 other children, adolescents, or adults to commit vio25 lence. 


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1 ‘‘(c) REQUIREMENTS.— 

2 ‘‘(1) IN GENERAL.—To be eligible for a grant, 

3 contract, or cooperative agreement under subsection 

4 (a), an entity shall— 

5 ‘‘(A) be a partnership that— 

6 ‘‘(i) shall include a State educational 

7 agency and one or more local educational 

8 agencies, with a local educational agency 

9 serving as the lead partner; and 

10 ‘‘(ii) may include, in accordance with 

11 paragraph (2)(A)(i), appropriate public or 

12 private entities that use evidence-based 

13 interventions, as defined in section 8101 of 

14 the Elementary and Secondary Education 

15 Act of 1965 (20 U.S.C. 7801); and 

16 ‘‘(B) submit an application, that is en17 dorsed by all members of the partnership, that 

18 contains the assurances described in paragraph 

19 (2). 

20 ‘‘(2) REQUIRED ASSURANCES.—An application 

21 under paragraph (1) shall contain assurances as fol22 lows: 

23 ‘‘(A) That the eligible entity will ensure 

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1 tion, the eligible entity will enter into a memo2 randum of understanding— 

3 ‘‘(i) with at least 1 public or private 

4 mental health entity, health care entity, 

5 law enforcement or juvenile justice entity, 

6 child welfare agency, family-based mental 

7 health entity, trauma network, or other 

8 community-based entity; and 

9 ‘‘(ii) that clearly states— 

10 ‘‘(I) the responsibilities of each 

11 partner with respect to the activities 

12 to be carried out, including how fam13 ily engagement will be incorporated in 

14 the activities; 

15 ‘‘(II) how school-employed and 

16 school-based mental health profes17 sionals will be utilized for carrying out 

18 such responsibilities; 

19 ‘‘(III) how each such partner will 

20 be accountable for carrying out such 

21 responsibilities; and 

22 ‘‘(IV) the amount of non-Federal 

23 funding or in-kind contributions that 

24 each such partner will contribute in 

25 order to sustain the program. 


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1 ‘‘(B) That the comprehensive school-based 

2 mental health program carried out under this 

3 section supports the flexible use of funds to ad4 dress— 

5 ‘‘(i) the promotion of the social, emo6 tional, and behavioral health of all students 

7 in an environment that is conducive to 

8 learning; 

9 ‘‘(ii) the reduction in the likelihood of 

10 at risk students developing social, emo11 tional, behavioral health problems, or sub12 stance use disorders; 

13 ‘‘(iii) the early identification of social, 

14 emotional, behavioral problems, or sub15 stance use disorders and the provision of 

16 early intervention services; 

17 ‘‘(iv) the treatment or referral for 

18 treatment of students with existing social, 

19 emotional, behavioral health problems, or 

20 substance use disorders; and 

21 ‘‘(v) the development and implementa22 tion of programs to assist children in deal23 ing with trauma and violence, including 

24 program curricula, school supports, and 

25 after-school programs. 


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1 ‘‘(C) That the comprehensive school-based 

2 mental health program carried out under this 

3 section will provide for in-service training of all 

4 school personnel, including ancillary staff and 

5 volunteers, in— 

6 ‘‘(i) the techniques and supports need7 ed to identify early children with trauma 

8 histories and children with, or at risk of, 

9 mental illness; 

10 ‘‘(ii) the use of referral mechanisms 

11 that effectively link such children to appro12 priate treatment and intervention services 

13 in the school and in the community and to 

14 follow-up when services are not available; 

15 ‘‘(iii) strategies that promote a school16 wide positive environment; 

17 ‘‘(iv) strategies for promoting the so18 cial, emotional, mental, and behavioral 

19 health of all students; and 

20 ‘‘(v) strategies to increase the knowl21 edge and skills of school and community 

22 leaders about the impact of trauma and vi23 olence and on the application of a public 

24 health approach to comprehensive school25 based mental health programs. 


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1 ‘‘(D) That the comprehensive school-based 

2 mental health program carried out under this 

3 section will include comprehensive training for 

4 parents, siblings, and other family members of 

5 children with mental health disorders, and for 

6 concerned members of the community in— 

7 ‘‘(i) the techniques and supports need8 ed to identify early children with trauma 

9 histories, and children with, or at risk of, 

10 mental illness; 

11 ‘‘(ii) the use of referral mechanisms 

12 that effectively link such children to appro13 priate treatment and intervention services 

14 in the school and in the community and 

15 follow-up when such services are not avail16 able; and 

17 ‘‘(iii) strategies that promote a school18 wide positive environment. 

19 ‘‘(E) That the comprehensive school-based 

20 mental health program carried out under this 

21 section will demonstrate the measures to be 

22 taken to sustain the program after funding 

23 under this section terminates (which may in24 clude seeking funding for the program under a 

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1 cial Security Act (42 U.S.C. 1396 et seq.) or a 

2 waiver of such a plan). 

3 ‘‘(F) That the eligible entity is supported 

4 by the State agency with primary responsibility 

5 for behavioral health to ensure that the sustain6 ability of the programs is established after 

7 funding under this section terminates. 

8 ‘‘(G) That the comprehensive school-based 

9 mental health program carried out under this 

10 section will be based on trauma-informed and 

11 evidence-based practices. 

12 ‘‘(H) That the comprehensive school-based 

13 mental health program carried out under this 

14 section will be coordinated with early inter15 vening activities carried out under the Individ16 uals with Disabilities Education Act. 

17 ‘‘(I) That the comprehensive school-based 

18 mental health program carried out under this 

19 section will be trauma-informed and culturally 

20 and linguistically appropriate. 

21 ‘‘(J) That the comprehensive school-based 

22 mental health program carried out under this 

23 section will include a broad needs assessment of 

24 youth who drop out of school due to policies of 

25 ‘zero tolerance’ with respect to drugs, alcohol, 


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1 or weapons and an inability to obtain appro2 priate services. 

3 ‘‘(K) That the mental health services pro4 vided through the comprehensive school-based 

5 mental health program carried out under this 

6 section will be provided by qualified mental and 

7 behavioral health professionals who are certified 

8 or licensed by the State involved and practicing 

9 within their area of expertise. 

10 ‘‘(3) COORDINATOR.—Any entity that is a 

11 member of a partnership described in paragraph 

12 (1)(A) may serve as the coordinator of funding and 

13 activities under the grant if all members of the part14 nership agree. 

15 ‘‘(4) COMPLIANCE WITH HIPAA.—A grantee 

16 under this section shall be deemed to be a covered 

17 entity for purposes of compliance with the regula18 tions promulgated under section 264(c) of the 

19 Health Insurance Portability and Accountability Act 

20 of 1996 with respect to any patient records devel21 oped through activities under the grant. 

22 ‘‘(d) GEOGRAPHICAL DISTRIBUTION.—The Secretary 

23 shall ensure that grants, contracts, or cooperative agree24 ments under subsection (a) will be distributed equitably 


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1 among the regions of the country and among urban and 

2 rural areas. 

3 ‘‘(e) DURATION OF AWARDS.—With respect to a 

4 grant, contract, or cooperative agreement under sub5 section (a), the period during which payments under such 

6 an award will be made to the recipient shall be 5 years. 

7 An eligible entity described in subsection (c) may receive 

8 only one award under this section, except that an eligible 

9 entity that is providing services and supports on a regional 

10 basis may receive additional funding after the expiration 

11 of the preceding grant period. 

12 ‘‘(f) EVALUATION AND MEASURES OF OUTCOMES.— 

13 ‘‘(1) DEVELOPMENT OF PROCESS.—The Ad14 ministrator shall develop a fiscally appropriate proc15 ess for evaluating activities carried out under this 

16 section. Such process shall include— 

17 ‘‘(A) the development of guidelines for the 

18 submission of program data by grant, contract, 

19 or cooperative agreement recipients; 

20 ‘‘(B) the development of measures of out21 comes (in accordance with paragraph (2)) to be 

22 applied by such recipients in evaluating pro23 grams carried out under this section; and 


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1 ‘‘(C) the submission of annual reports by 

2 such recipients concerning the effectiveness of 

3 programs carried out under this section. 

4 ‘‘(2) MEASURES OF OUTCOMES.— 

5 ‘‘(A) IN GENERAL.—The Administrator 

6 shall develop measures of outcomes to be ap7 plied by recipients of assistance under this sec8 tion, and the Administrator, in evaluating the 

9 effectiveness of programs carried out under this 

10 section. Such measures shall include student 

11 and family measures as provided for in sub12 paragraph (B) and local educational measures 

13 as provided for under subparagraph (C). 

14 ‘‘(B) STUDENT AND FAMILY MEASURES OF

15 OUTCOMES.—The measures of outcomes devel16 oped under paragraph (1)(B) relating to stu17 dents and families shall, with respect to activi18 ties carried out under a program under this 

19 section, at a minimum include provisions to 

20 evaluate whether the program is effective in— 

21 ‘‘(i) increasing social and emotional 

22 competency; 

23 ‘‘(ii) increasing academic competency 

24 (as defined by the Secretary); 


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1 ‘‘(iii) reducing disruptive and aggres2 sive behaviors; 

3 ‘‘(iv) improving child functioning; 

4 ‘‘(v) reducing substance use disorders; 

5 ‘‘(vi) reducing suspensions, truancy, 

6 expulsions, and violence; 

7 ‘‘(vii) increasing high school gradua8 tion rates, calculated using the four-year 

9 adjusted cohort graduation rate or the ex10 tended-year adjusted cohort graduation 

11 rate (as such terms are defined in section 

12 8101 of the Elementary and Secondary 

13 Education Act of 1965 (20 U.S.C. 7801)); 

14 and 

15 ‘‘(viii) improving access to care for 

16 mental health disorders. 

17 ‘‘(C) LOCAL EDUCATIONAL OUTCOMES.— 

18 The outcome measures developed under para19 graph (1)(B) relating to local educational sys20 tems shall, with respect to activities carried out 

21 under a program under this section, at a min22 imum include provisions to evaluate— 

23 ‘‘(i) the effectiveness of comprehensive 

24 school mental health programs established 

25 under this section; 


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1 ‘‘(ii) the effectiveness of formal part2 nership linkages among child and family 

3 serving institutions, community support 

4 systems, and the educational system; 

5 ‘‘(iii) the progress made in sustaining 

6 the program once funding under the grant 

7 has expired; 

8 ‘‘(iv) the effectiveness of training and 

9 professional development programs for all 

10 school personnel that incorporate indica11 tors that measure cultural and linguistic 

12 competencies under the program in a man13 ner that incorporates appropriate cultural 

14 and linguistic training; 

15 ‘‘(v) the improvement in perception of 

16 a safe and supportive learning environment 

17 among school staff, students, and parents; 

18 ‘‘(vi) the improvement in case-finding 

19 of students in need of more intensive serv20 ices and referral of identified students to 

21 early intervention and clinical services; 

22 ‘‘(vii) the improvement in the imme23 diate availability of clinical assessment and 

24 treatment services within the context of 


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1 the local community to students posing a 

2 danger to themselves or others; 

3 ‘‘(viii) the increased successful matric4 ulation to postsecondary school; and 

5 ‘‘(ix) reduced referrals to juvenile jus6 tice. 

7 ‘‘(3) SUBMISSION OF ANNUAL DATA.—An eligi8 ble entity described in subsection (c) that receives a 

9 grant, contract, or cooperative agreement under this 

10 section shall annually submit to the Administrator a 

11 report that includes data to evaluate the success of 

12 the program carried out by the entity based on 

13 whether such program is achieving the purposes of 

14 the program. Such reports shall utilize the measures 

15 of outcomes under paragraph (2) in a reasonable 

16 manner to demonstrate the progress of the program 

17 in achieving such purposes. 

18 ‘‘(4) EVALUATION BY ADMINISTRATOR.—Based 

19 on the data submitted under paragraph (3), the Ad20 ministrator shall annually submit to Congress a re21 port concerning the results and effectiveness of the 

22 programs carried out with assistance received under 

23 this section. 

24 ‘‘(5) LIMITATION.—An eligible entity shall use 

25 not more than 10 percent of amounts received under 


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1 a grant under this section to carry out evaluation 

2 activities under this subsection. 

3 ‘‘(g) INFORMATION AND EDUCATION.—The Sec4 retary shall establish comprehensive information and edu5 cation programs to disseminate the findings of the knowl6 edge development and application under this section to the 

7 general public and to health care professionals. 

8 ‘‘(h) AMOUNT OF GRANTS AND AUTHORIZATION OF

9 APPROPRIATIONS.— 

10 ‘‘(1) AMOUNT OF GRANTS.—A grant under this 

11 section shall be in an amount that is not more than 

12 $2,000,000 for each of fiscal years 2019 through 

13 2023. The Secretary shall determine the amount of 

14 each such grant based on the population of children 

15 up to age 21 of the area to be served under the 

16 grant. 

17 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

18 There is authorized to be appropriated to carry out 

19 this section, $200,000,000 for each of fiscal years 

20 2019 through 2023.’’. 

21 (d) CONFORMING AMENDMENT.—Part G of title V 

22 of the Public Health Service Act (42 U.S.C. 290hh et 

23 seq.), as amended by this section, is further amended by 

24 striking the part heading and inserting the following: 


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1 ‘‘PART G—SCHOOL-BASED MENTAL HEALTH’’. 

2 SEC. 608. GEO-ACCESS STUDY. 

3 The Administrator of the Substance Abuse and Men4 tal Health Services Administration shall— 

5 (1) conduct a study to— 

6 (A) determine which geographic areas of 

7 the United States have shortages of specialty 

8 mental health providers; and 

9 (B) assess the preparedness of speciality 

10 mental health providers to deliver culturally and 

11 linguistically appropriate, affordable, and acces12 sible services; and 

13 (2) submit a report to the Congress on the re14 sults of such study. 

15 TITLE VII—ADDRESSING HIGH 

16 IMPACT MINORITY DISEASES 

17 Subtitle A—Cancer 

18 SEC. 701. LUNG CANCER MORTALITY REDUCTION. 

19 (a) SHORT TITLE.—This section may be cited as the 

20 ‘‘Lung Cancer Mortality Reduction Act of 2018’’. 

21 (b) FINDINGS.—Congress makes the following find22 ings: 

23 (1) Lung cancer is the leading cause of cancer 

24 death for both men and women, accounting for 28 

25 percent of all cancer deaths. 


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1 (2) Lung cancer kills more people annually 

2 than breast cancer, prostate cancer, colon cancer, 

3 liver cancer, melanoma, and kidney cancer combined. 

4 (3) Since the National Cancer Act of 1971 

5 (Public Law 92–218; 85 Stat. 778), coordinated and 

6 comprehensive research has raised the 5-year sur7 vival rates for breast cancer to 88 percent, for pros8 tate cancer to 99 percent, and for colon cancer to 

9 64 percent. 

10 (4) The 5-year survival rate for lung cancer is 

11 still only 15 percent, and a similar coordinated and 

12 comprehensive research effort is required to achieve 

13 increases in lung cancer survivability rates. 

14 (5) Sixty percent of lung cancer cases are now 

15 diagnosed as nonsmokers or former smokers. 

16 (6) Two-thirds of nonsmokers diagnosed with 

17 lung cancer are women. 

18 (7) Certain minority populations, such as Afri19 can American males, have disproportionately high 

20 rates of lung cancer incidence and mortality, not21 withstanding their similar smoking rate. 

22 (8) Members of the baby boomer generation are 

23 entering their sixties, the most common age at which 

24 people develop lung cancer. 


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1 (9) Tobacco addiction and exposure to other 

2 lung cancer carcinogens such as Agent Orange and 

3 other herbicides and battlefield emissions are serious 

4 problems among military personnel and war vet5 erans. 

6 (10) Significant and rapid improvements in 

7 lung cancer mortality can be expected through great8 er use and access to lung cancer screening tests for 

9 at-risk individuals. 

10 (11) Recent research has shown that screening 

11 with low-dose computed tomography (CT) scan im12 proved lung cancer death mortality by 20 percent for 

13 those with a high risk of lung cancer through early 

14 detection. The Centers for Medicare & Medicaid 

15 Services supports annual lung cancer screening for 

16 high-risk patients with low-dose computed tomog17 raphy. 

18 (12) Additional strategies are necessary to fur19 ther enhance the existing tests and therapies avail20 able to diagnose and treat lung cancer in the future. 

21 (13) The August 2001 Report of the Lung 

22 Cancer Progress Review Group of the National Can23 cer Institute stated that funding for lung cancer re24 search was ‘‘far below the levels characterized for 


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1 other common malignancies and far out of propor2 tion to its massive health impact’’. 

3 (14) The Report of the Lung Cancer Progress 

4 Review Group identified as its ‘‘highest priority’’ the 

5 creation of integrated, multidisciplinary, multi-insti6 tutional research consortia organized around the 

7 problem of lung cancer rather than around specific 

8 research disciplines. 

9 (15) The United States must enhance its re10 sponse to the issues raised in the Report of the 

11 Lung Cancer Progress Review Group, and this can 

12 be accomplished through the establishment of a co13 ordinated effort designed to reduce the lung cancer 

14 mortality rate by 50 percent by 2020 and targeted 

15 funding to support this coordinated effort. 

16 (c) SENSE OF CONGRESS CONCERNING INVESTMENT

17 IN LUNG CANCER RESEARCH.—It is the sense of the Con18 gress that— 

19 (1) lung cancer mortality reduction should be 

20 made a national public health priority; and 

21 (2) a comprehensive mortality reduction pro22 gram coordinated by the Secretary of Health and 

23 Human Services is justified and necessary to ade24 quately address and reduce lung cancer mortality. 


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1 (d) LUNG CANCER MORTALITY REDUCTION PRO2 GRAM.— 

3 (1) IN GENERAL.—Subpart 1 of part C of title 

4 IV of the Public Health Service Act (42 U.S.C. 285 

5 et seq.) is amended by adding at the end the fol6 lowing: 

7 ‘‘SEC. 417H. LUNG CANCER MORTALITY REDUCTION PRO8 GRAM. 

9 ‘‘(a) IN GENERAL.—Not later than 6 months after 

10 the date of the enactment of this section, the Secretary, 

11 in consultation with the Secretary of Defense, the Sec12 retary of Veterans Affairs, the Director of the National 

13 Institutes of Health, the Director of the Centers for Dis14 ease Control and Prevention, the Commissioner of Food 

15 and Drugs, the Administrator of the Centers for Medicare 

16 & Medicaid Services, the Director of the National Institute 

17 on Minority Health and Health Disparities, and other 

18 members of the Lung Cancer Advisory Board established 

19 under section 701 of the Health Equity and Accountability 

20 Act of 2018, shall implement a comprehensive program, 

21 to be known as the Lung Cancer Mortality Reduction Pro22 gram, to achieve a reduction of at least 25 percent in the 

23 mortality rate of lung cancer by 2020. 

24 ‘‘(b) REQUIREMENTS.—The Program shall include at 

25 least the following: 


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1 ‘‘(1) With respect to the National Institutes of 

2 Health— 

3 ‘‘(A) a strategic review and prioritization 

4 by the National Cancer Institute of research 

5 grants to achieve the goal of the Lung Cancer 

6 Mortality Reduction Program in reducing lung 

7 cancer mortality; 

8 ‘‘(B) the provision of funds to enable the 

9 Airway Biology and Disease Branch of the Na10 tional Heart, Lung, and Blood Institute to ex11 pand its research programs to include pre12 dispositions to lung cancer, the interrelationship 

13 between lung cancer and other pulmonary and 

14 cardiac disease, and the diagnosis and treat15 ment of these interrelationships; 

16 ‘‘(C) the provision of funds to enable the 

17 National Institute of Biomedical Imaging and 

18 Bioengineering to expedite the development of 

19 computer-assisted diagnostic, surgical, treat20 ment, and drug-testing innovations to reduce 

21 lung cancer mortality, such as through expan22 sion of the Institute’s Quantum Grant Program 

23 and Image-Guided Interventions programs; and 

24 ‘‘(D) the provision of funds to enable the 

25 National Institute of Environmental Health 


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1 Sciences to implement research programs rel2 ative to the lung cancer incidence. 

3 ‘‘(2) With respect to the Food and Drug Ad4 ministration— 

5 ‘‘(A) activities under section 530 of the 

6 Federal Food, Drug, and Cosmetic Act; and 

7 ‘‘(B) activities under section 561 of the 

8 Federal Food, Drug, and Cosmetic Act to ex9 pand access to investigational drugs and devices 

10 for the diagnosis, monitoring, or treatment of 

11 lung cancer. 

12 ‘‘(3) With respect to the Centers for Disease 

13 Control and Prevention, the establishment of an 

14 early disease research and management program 

15 under section 1511. 

16 ‘‘(4) With respect to the Agency for Healthcare 

17 Research and Quality, the conduct of a biannual re18 view of lung cancer screening, diagnostic, and treat19 ment protocols, and the issuance of updated guide20 lines. 

21 ‘‘(5) The promotion (including education) of 

22 lung cancer screening within minority and rural pop23 ulations and the study of the effectiveness of efforts 

24 to increase such screening. 


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1 ‘‘(6) The cooperation and coordination of all 

2 minority and health disparity programs within the 

3 Department of Health and Human Services to en4 sure that all aspects of the Lung Cancer Mortality 

5 Reduction Program under this section adequately 

6 address the burden of lung cancer on minority and 

7 rural populations. 

8 ‘‘(7) The cooperation and coordination of all to9 bacco control and cessation programs within agen10 cies of the Department of Health and Human Serv11 ices to achieve the goals of the Lung Cancer Mor12 tality Reduction Program under this section with 

13 particular emphasis on the coordination of drug and 

14 other cessation treatments with early detection pro15 tocols.’’. 

16 (2) FEDERAL FOOD, DRUG, AND COSMETIC

17 ACT.—Subchapter B of chapter V of the Federal 

18 Food, Drug, and Cosmetic Act (21 U.S.C. 360aaa et 

19 seq.) is amended by adding at the end the following: 

20 ‘‘DRUGS RELATING TO LUNG CANCER

21 ‘‘SEC. 530. (a) IN GENERAL.—The provisions of this 

22 subchapter shall apply to a drug described in subsection 

23 (b) to the same extent and in the same manner as such 

24 provisions apply to a drug for a rare disease or condition. 

25 ‘‘(b) QUALIFIED DRUGS.—A drug described in this 

26 subsection is— 


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1 ‘‘(1) a chemoprevention drug for precancerous 

2 conditions of the lung; 

3 ‘‘(2) a drug for targeted therapeutic treat4 ments, including any vaccine, for lung cancer; and 

5 ‘‘(3) a drug to curtail or prevent nicotine addic6 tion. 

7 ‘‘(c) BOARD.—The Board established under the 

8 Health Equity and Accountability Act of 2018 shall mon9 itor the program implemented under this section.’’. 

10 (3) ACCESS TO UNAPPROVED THERAPIES.—Sec11 tion 561(e) of the Federal Food, Drug, and Cos12 metic Act (21 U.S.C. 360bbb(e)) is amended by in13 serting before the period the following: ‘‘and shall 

14 include expanding access to drugs under section 

15 530, with substantial consideration being given to 

16 whether the totality of information available to the 

17 Secretary regarding the safety and effectiveness of 

18 an investigational drug, as compared to the risk of 

19 morbidity and death from the disease, indicates that 

20 a patient may obtain more benefit than risk if treat21 ed with the drug’’. 

22 (4) CDC.—Title XV of the Public Health Serv23 ice Act (42 U.S.C. 300k et seq.) is amended by add24 ing at the end the following: 


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1 ‘‘SEC. 1511. EARLY DISEASE RESEARCH AND MANAGEMENT 

2 PROGRAM. 

3 ‘‘The Secretary shall establish and implement an 

4 early disease research and management program targeted 

5 at the high incidence and mortality rates of lung cancer 

6 among minority and low-income populations.’’. 

7 (e) DEPARTMENT OF DEFENSE AND THE DEPART8 MENT OF VETERANS AFFAIRS.—The Secretary of Defense 

9 and the Secretary of Veterans Affairs shall coordinate 

10 with the Secretary of Health and Human Services— 

11 (1) in the development of the Lung Cancer 

12 Mortality Reduction Program under section 417H; 

13 (2) in the implementation within the Depart14 ment of Defense and the Department of Veterans 

15 Affairs of an early detection and disease manage16 ment research program for military personnel and 

17 veterans whose smoking history and exposure to car18 cinogens during active duty service has increased 

19 their risk for lung cancer; and 

20 (3) in the implementation of coordinated care 

21 programs for military personnel and veterans diag22 nosed with lung cancer. 

23 (f) LUNG CANCER ADVISORY BOARD.— 

24 (1) IN GENERAL.—The Secretary of Health and 

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1 sory Board (referred to in this section as the 

2 ‘‘Board’’)— 

3 (A) to monitor the programs established 

4 under this section (and the amendments made 

5 by this section); and 

6 (B) to provide annual reports to the Con7 gress concerning benchmarks, expenditures, 

8 lung cancer statistics, and the public health im9 pact of such programs. 

10 (2) COMPOSITION.—The Board shall be com11 posed of— 

12 (A) the Secretary of Health and Human 

13 Services; 

14 (B) the Secretary of Defense; 

15 (C) the Secretary of Veterans Affairs; and 

16 (D) two representatives each from the 

17 fields of clinical medicine focused on lung can18 cer, lung cancer research, imaging, drug devel19 opment, and lung cancer advocacy, to be ap20 pointed by the Secretary of Health and Human 

21 Services. 

22 (g) AUTHORIZATION OF APPROPRIATIONS.— 

23 (1) IN GENERAL.—To carry out this section 

24 (and the amendments made by this section), there 

25 are authorized to be appropriated such sums as may 


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1 be necessary for each of fiscal years 2019 through 

2 2023. 

3 (2) LUNG CANCER MORTALITY REDUCTION PRO4 GRAM.—Of the amounts authorized to be appro5 priated by subsection (a), there are authorized to be 

6 appropriated— 

7 (A) $25,000,000 for fiscal year 2019, and 

8 such sums as may be necessary for each of fis9 cal years 2020 through 2023, for the activities 

10 described in section 417H(b)(1)(B) of the Pub11 lic Health Service Act, as added by subsection 

12 (d)(1); 

13 (B) $25,000,000 for fiscal year 2019, and 

14 such sums as may be necessary for each of fis15 cal years 2020 through 2023, for the activities 

16 described in section 417H(b)(1)(C) of such Act; 

17 (C) $10,000,000 for fiscal year 2019, and 

18 such sums as may be necessary for each of fis19 cal years 2020 through 2023, for the activities 

20 described in section 417H(b)(1)(D) of such Act; 

21 and 

22 (D) $15,000,000 for fiscal year 2019, and 

23 such sums as may be necessary for each of fis24 cal years 2020 through 2023, for the activities 

25 described in section 417H(b)(3) of such Act. 


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1 SEC. 702. EXPANDING PROSTATE CANCER RESEARCH, OUT2 REACH, SCREENING, TESTING, ACCESS, AND 

3 TREATMENT EFFECTIVENESS. 

4 (a) SHORT TITLE.—This section may be cited as the 

5 ‘‘Prostate Research, Outreach, Screening, Testing, Access, 

6 and Treatment Effectiveness Act of 2018’’ or the ‘‘PROS7 TATE Act’’. 

8 (b) FINDINGS.—Congress makes the following find9 ings: 

10 (1) Prostate cancer is the second leading cause 

11 of cancer death among men. 

12 (2) In 2010, more than 217,730 new patients 

13 were diagnosed with prostate cancer and more than 

14 32,000 men died from this disease. 

15 (3) Roughly 2,000,000 Americans are living 

16 with a diagnosis of prostate cancer and its con17 sequences. 

18 (4) While prostate cancer generally affects older 

19 individuals, younger men are also at risk for the dis20 ease, and when prostate cancer appears in early 

21 middle age, it frequently takes on a more aggressive 

22 form. 

23 (5) There are significant racial and ethnic dis24 parities that demand attention, namely African 

25 Americans have prostate cancer mortality rates that 

26 are more than double those in the White population. 


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1 (6) Underserved rural populations have higher 

2 rates of mortality compared to their urban counter3 parts, and innovative and cost-efficient methods to 

4 improve rural access to high-quality care should take 

5 advantage of advances in telehealth to diagnose and 

6 treat prostate cancer when appropriate. 

7 (7) Certain veterans populations may have 

8 nearly twice the incidence of prostate cancer as the 

9 general population of the United States. 

10 (8) Urologists may constitute the specialists 

11 who diagnose and treat the vast majority of prostate 

12 cancer patients. 

13 (9) Although much basic and translational re14 search has been completed and much is currently 

15 known, there are still many unanswered questions. 

16 For example, it is not fully understood how much of 

17 known disparities are attributable to disease eti18 ology, access to care, or education and awareness in 

19 the community. 

20 (10) Causes of prostate cancer are not known. 

21 There is not good information regarding how to dif22 ferentiate accurately, early on, between aggressive 

23 and indolent forms of the disease. As a result, there 

24 is significant overtreatment in prostate cancer. 

25 There are no treatments that can durably arrest 


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1 growth or cure prostate cancer once it has metasta2 sized. 

3 (11) A significant proportion (roughly 23 to 54 

4 percent) of cases may be clinically indolent and 

5 ‘‘overdiagnosed’’, resulting in significant overtreat6 ment. More accurate tests will allow men and their 

7 families to face less physical, psychological, financial, 

8 and emotional trauma, and billions of dollars could 

9 be saved in private and public health care systems 

10 in an area that has been identified by the Medicare 

11 Program as one of eight high-volume, high-cost 

12 areas in the Resource Utilization Report Program 

13 authorized by Congress under the Medicare Im14 provements for Patients and Providers Act of 2008. 

15 (12) Prostate cancer research and health care 

16 programs across Federal agencies should be coordi17 nated to improve accountability and actively encour18 age the translation of research into practice, to iden19 tify and implement best practices, in order to foster 

20 an integrated and consistent focus on effective pre21 vention, diagnosis, and treatment of this disease. 

22 (c) PROSTATE CANCER COORDINATION AND EDU23 CATION.— 

24 (1) INTERAGENCY PROSTATE CANCER COORDI25 NATION AND EDUCATION TASK FORCE.—Not later 


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1 than 180 days after the date of the enactment of 

2 this section, the Secretary of Veterans Affairs, in co3 operation with the Secretary of Defense and the Sec4 retary of Health and Human Services, shall estab5 lish an Interagency Prostate Cancer Coordination 

6 and Education Task Force (in this section referred 

7 to as the ‘‘Prostate Cancer Task Force’’). 

8 (2) DUTIES.—The Prostate Cancer Task Force 

9 shall— 

10 (A) develop a summary of advances in 

11 prostate cancer research supported or con12 ducted by Federal agencies relevant to the diag13 nosis, prevention, and treatment of prostate 

14 cancer, including psychosocial impairments re15 lated to prostate cancer treatment, and compile 

16 a list of best practices that warrant broader 

17 adoption in health care programs; 

18 (B) consider establishing, and advocating 

19 for, a guidance to enable physicians to allow 

20 screening of men who are over age 74, on a 

21 case-by-case basis, taking into account quality 

22 of life and family history of prostate cancer; 

23 (C) share and coordinate information on 

24 Federal research and health care program ac25 tivities, including activities related to— 


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1 (i) determining how to improve re2 search and health care programs, including 

3 psychosocial impairments related to pros4 tate cancer treatment; 

5 (ii) identifying any gaps in the overall 

6 research inventory and in health care pro7 grams; 

8 (iii) identifying opportunities to pro9 mote translation of research into practice; 

10 and 

11 (iv) maximizing the effects of Federal 

12 efforts by identifying opportunities for col13 laboration and leveraging of resources in 

14 research and health care programs that 

15 serve those susceptible to or diagnosed 

16 with prostate cancer; 

17 (D) develop a comprehensive interagency 

18 strategy and advise relevant Federal agencies in 

19 the solicitation of proposals for collaborative, 

20 multidisciplinary research and health care pro21 grams, including proposals to evaluate factors 

22 that may be related to the etiology of prostate 

23 cancer, that would— 

24 (i) result in innovative approaches to 

25 study emerging scientific opportunities or 


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1 eliminate knowledge gaps in research to 

2 improve the prostate cancer research port3 folio of the Federal Government; 

4 (ii) outline key research questions, 

5 methodologies, and knowledge gaps; and 

6 (iii) ensure consistent action, as out7 lined by section 402(b) of the Public 

8 Health Service Act; 

9 (E) develop a coordinated message related 

10 to screening and treatment for prostate cancer 

11 to be reflected in educational and beneficiary 

12 materials for Federal health programs as such 

13 documents are updated; and 

14 (F) not later than 2 years after the date 

15 of the establishment of the Prostate Cancer 

16 Task Force, submit to the Expert Advisory 

17 Panel to be reviewed and returned within 30 

18 days, and then within 90 days submitted to 

19 Congress recommendations— 

20 (i) regarding any appropriate changes 

21 to research and health care programs, in22 cluding recommendations to improve the 

23 research portfolio of the Department of 

24 Veterans Affairs, the Department of De25 fense, National Institutes of Health, and 


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1 other Federal agencies to ensure that sci2 entifically based strategic planning is im3 plemented in support of research and 

4 health care program priorities; 

5 (ii) designed to ensure that the re6 search and health care programs and ac7 tivities of the Department of Veterans Af8 fairs, the Department of Defense, the De9 partment of Health and Human Services, 

10 and other Federal agencies are free of un11 necessary duplication; 

12 (iii) regarding public participation in 

13 decisions relating to prostate cancer re14 search and health care programs to in15 crease the involvement of patient advo16 cates, community organizations, and med17 ical associations representing a broad geo18 graphical area; 

19 (iv) on how to best disseminate infor20 mation on prostate cancer research and 

21 progress achieved by health care programs; 

22 (v) about how to expand partnerships 

23 between public entities, including Federal 

24 agencies, and private entities to encourage 


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1 collaborative, cross-cutting research and 

2 health care delivery; 

3 (vi) assessing any cost savings and ef4 ficiencies realized through the efforts iden5 tified and supported in this section and 

6 recommending expansion of those efforts 

7 that have proved most promising while also 

8 ensuring against any conflicts in directives 

9 from other congressional or statutory man10 dates or enabling statutes; 

11 (vii) identifying key priority action 

12 items from among the recommendations; 

13 and 

14 (viii) with respect to the level of fund15 ing needed by each agency to implement 

16 the recommendations contained in the re17 port. 

18 (3) MEMBERS OF THE PROSTATE CANCER TASK

19 FORCE.—The Prostate Cancer Task Force described 

20 in this subsection shall be composed of representa21 tives from such Federal agencies, as each Secretary 

22 determines necessary, to coordinate a uniform mes23 sage relating to prostate cancer screening and treat24 ment where appropriate, including representatives of 

25 the following: 


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1 (A) The Department of Veterans Affairs, 

2 including representatives of each relevant pro3 gram area of the Department of Veterans Af4 fairs. 

5 (B) The Prostate Cancer Research Pro6 gram of the Congressionally Directed Medical 

7 Research Program of the Department of De8 fense. 

9 (C) The Department of Health and 

10 Human Services, including at a minimum rep11 resentatives of the following: 

12 (i) The National Institutes of Health. 

13 (ii) National research institutes and 

14 centers, including the National Cancer In15 stitute, the National Institute of Allergy 

16 and Infectious Diseases, and the Office of 

17 Minority Health. 

18 (iii) The Centers for Medicare & Med19 icaid Services. 

20 (iv) The Food and Drug Administra21 tion. 

22 (v) The Centers for Disease Control 

23 and Prevention. 

24 (vi) The Agency for Healthcare Re25 search and Quality. 


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1 (vii) The Health Resources and Serv2 ices Administration. 

3 (4) APPOINTING EXPERT ADVISORY PANELS.— 

4 The Prostate Cancer Task Force shall appoint ex5 pert advisory panels, as determined appropriate, to 

6 provide input and concurrence from individuals and 

7 organizations from the medical, prostate cancer pa8 tient and advocate, research, and delivery commu9 nities with expertise in prostate cancer diagnosis, 

10 treatment, and research, including practicing urolo11 gists, primary care providers, and others and indi12 viduals with expertise in education and outreach to 

13 underserved populations affected by prostate cancer. 

14 (5) MEETINGS.—The Prostate Cancer Task 

15 Force shall convene not less than twice a year, or 

16 more frequently as the Secretary determines to be 

17 appropriate. 

18 (6) FEDERAL ADVISORY COMMITTEE ACT.— 

19 (A) IN GENERAL.—Except as provided in 

20 subparagraph (B), the Federal Advisory Com21 mittee Act (5 U.S.C. App.) shall apply to the 

22 Prostate Cancer Task Force. 

23 (B) EXCEPTION.—Section 14(a)(2)(B) of 

24 such Act (relating to the termination of adviVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00516 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 sory committees) shall not apply to the Prostate 

2 Cancer Task Force. 

3 (7) SUNSET DATE.—The Prostate Cancer Task 

4 Force shall terminate at the end of fiscal year 2021. 

5 (d) PROSTATE CANCER RESEARCH.— 

6 (1) RESEARCH COORDINATION.—The Secretary 

7 of Veterans Affairs, in coordination with the Secre8 taries of Defense and of Health and Human Serv9 ices, shall establish and carry out a program to co10 ordinate and intensify prostate cancer research as 

11 needed. Specifically, such research program shall— 

12 (A) develop advances in diagnostic and 

13 prognostic methods and tests, including bio14 markers and an improved prostate cancer 

15 screening blood test, including improvements or 

16 alternatives to the prostate specific antigen test 

17 and additional tests to distinguish indolent from 

18 aggressive disease; 

19 (B) better understand the etiology of the 

20 disease (including an analysis of lifestyle factors 

21 proven to be involved in higher rates of prostate 

22 cancer, such as obesity and diet, and in dif23 ferent ethnic, racial, and socioeconomic groups, 

24 such as the African-American, Latino or His25 panic, and American Indian populations and 


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1 men with a family history of prostate cancer) to 

2 improve prevention efforts; 

3 (C) expand basic research into prostate 

4 cancer, including studies of fundamental molec5 ular and cellular mechanisms; 

6 (D) identify and provide clinical testing of 

7 novel agents for the prevention and treatment 

8 of prostate cancer; 

9 (E) establish clinical registries for prostate 

10 cancer; 

11 (F) use the National Institute of Bio12 medical Imaging and Bioengineering and the 

13 National Cancer Institute for assessment of ap14 propriate imaging modalities; and 

15 (G) address such other matters relating to 

16 prostate cancer research as may be identified by 

17 the Federal agencies participating in the pro18 gram under this section. 

19 (2) PROSTATE CANCER ADVISORY BOARD.— 

20 There is established in the Office of the Chief Sci21 entist of the Food and Drug Administration a Pros22 tate Cancer Scientific Advisory Board. Such board 

23 shall be responsible for accelerating real-time shar24 ing of the latest research data and accelerating 

25 movement of new medicines to patients. 


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1 (3) UNDERSERVED MINORITY GRANT PRO2 GRAM.—In carrying out such program, the Secretary 

3 shall— 

4 (A) award grants to eligible entities to 

5 carry out components of the research outlined 

6 in paragraph (1); 

7 (B) integrate and build upon existing 

8 knowledge gained from comparative effective9 ness research; and 

10 (C) recognize and address— 

11 (i) the racial and ethnic disparities in 

12 the incidence and mortality rates of pros13 tate cancer and men with a family history 

14 of prostate cancer; 

15 (ii) any barriers in access to care and 

16 participation in clinical trials that are spe17 cific to racial, ethnic, and other under18 served minorities and men with a family 

19 history of prostate cancer; 

20 (iii) needed outreach and educational 

21 efforts to raise awareness in these commu22 nities; and 

23 (iv) appropriate access and utilization 

24 of imaging modalities. 


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1 (e) TELEHEALTH AND RURAL ACCESS PILOT

2 PROJECTS.— 

3 (1) IN GENERAL.—The Secretary of Veterans 

4 Affairs, the Secretary of Defense, and the Secretary 

5 of Health and Human Services (in this section re6 ferred to as the ‘‘Secretaries’’) shall establish 4-year 

7 telehealth pilot projects for the purpose of analyzing 

8 the clinical outcomes and cost-effectiveness associ9 ated with telehealth services in a variety of geo10 graphic areas that contain high proportions of medi11 cally underserved populations, including African 

12 Americans, Latinos or Hispanics, American Indians 

13 or Alaska Natives, and those in rural areas. Such 

14 projects shall promote efficient use of specialist care 

15 through better coordination of primary care and 

16 physician extender teams in underserved areas and 

17 more effectively employ tumor boards to better coun18 sel patients. 

19 (2) ELIGIBLE ENTITIES.— 

20 (A) IN GENERAL.—The Secretaries shall 

21 select eligible entities to participate in the pilot 

22 projects under this section. 

23 (B) PRIORITY.—In selecting eligible enti24 ties to participate in the pilot projects under 

25 this section, the Secretaries shall give priority 


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1 to such entities located in medically under2 served areas, particularly those that include Af3 rican Americans, Latinos and Hispanics, and 

4 facilities of the Indian Health Service, including 

5 Indian Health Service-operated facilities, trib6 ally operated facilities, and Urban Indian Clin7 ics, and those in rural areas. 

8 (3) EVALUATION.—The Secretaries shall, 

9 through the pilot projects, evaluate— 

10 (A) the effective and economic delivery of 

11 care in diagnosing and treating prostate cancer 

12 with the use of telehealth services in medically 

13 underserved and Tribal areas including collabo14 rative uses of health professionals and integra15 tion of the range of telehealth and other tech16 nologies; 

17 (B) the effectiveness of improving the ca18 pacity of nonmedical providers and nonspecial19 ized medical providers to provide health services 

20 for prostate cancer in medically underserved 

21 and Tribal areas, including the exploration of 

22 innovative medical home models with collabora23 tion between urologists, other relevant medical 

24 specialists, including oncologists, radiologists, 

25 and primary care teams and coordination of 


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1 care through the efficient use of primary care 

2 teams and physician extenders; and 

3 (C) the effectiveness of using telehealth 

4 services to provide prostate cancer treatment in 

5 medically underserved areas, including the use 

6 of tumor boards to facilitate better patient 

7 counseling. 

8 (4) REPORT.—Not later than 12 months after 

9 the completion of the pilot projects under this sub10 section, the Secretaries shall submit to Congress a 

11 report describing the outcomes of such pilot projects, 

12 including any cost savings and efficiencies realized, 

13 and providing recommendations, if any, for expand14 ing the use of telehealth services. 

15 (f) EDUCATION AND AWARENESS.— 

16 (1) IN GENERAL.—The Secretary of Veterans 

17 Affairs shall develop a national education campaign 

18 for prostate cancer. Such campaign shall involve the 

19 use of written educational materials and public serv20 ice announcements consistent with the findings of 

21 the Prostate Cancer Task Force under subsection 

22 (c), that are intended to encourage men to seek 

23 prostate cancer screening when appropriate. 

24 (2) RACIAL DISPARITIES AND THE POPULATION

25 OF MEN WITH A FAMILY HISTORY OF PROSTATE


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1 CANCER.—In developing the national campaign 

2 under paragraph (1), the Secretary shall ensure that 

3 such educational materials and public service an4 nouncements are more readily available in commu5 nities experiencing racial disparities in the incidence 

6 and mortality rates of prostate cancer and by men 

7 of any race classification with a family history of 

8 prostate cancer. 

9 (3) GRANTS.—In carrying out the national 

10 campaign under this section, the Secretary shall 

11 award grants to nonprofit private entities to enable 

12 such entities to test alternative outreach and edu13 cation strategies. 

14 (g) AUTHORIZATION OF APPROPRIATIONS.— 

15 (1) IN GENERAL.—There is authorized to be 

16 appropriated to carry out this section for the period 

17 of fiscal years 2019 through 2023 an amount equal 

18 to the savings described in paragraph (2). 

19 (2) CORRESPONDING REDUCTION.—The 

20 amount authorized to be appropriated by provisions 

21 of law other than this section for the period of fiscal 

22 years 2019 through 2023 for Federal research and 

23 health care program activities related to prostate 

24 cancer is reduced by the amount of Federal savings 


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1 projected to be achieved over such period by imple2 mentation of this section. 

3 SEC. 703. IMPROVED MEDICAID COVERAGE FOR CERTAIN 

4 BREAST AND CERVICAL CANCER PATIENTS 

5 IN THE TERRITORIES. 

6 (a) ELIMINATION OF FUNDING LIMITATIONS.— 

7 (1) IN GENERAL.—Section 1108(g)(4) of the 

8 Social Security Act (42 U.S.C. 1308(g)(4)) is 

9 amended by adding at the end the following: ‘‘With 

10 respect to fiscal years beginning with fiscal year 

11 2019, payment for medical assistance for individuals 

12 who are eligible for such assistance only on the basis 

13 of section 1902(a)(10)(A)(ii)(XVIII) shall not be 

14 taken into account in applying subsection (f) (as in15 creased in accordance with paragraphs (1), (2), (3), 

16 and (5) of this subsection) to such commonwealth or 

17 territory for such fiscal year.’’. 

18 (2) TECHNICAL AMENDMENT.—Such section is 

19 further amended by striking ‘‘(3), and (4)’’ and in20 serting ‘‘(3), and (5)’’. 

21 (b) APPLICATION OF ENHANCED FMAP FOR HIGH22 EST STATE.—Section 1905(b) of such Act (42 U.S.C. 

23 1396d(b)) is amended by adding at the end the following: 

24 ‘‘Notwithstanding the first sentence of this subsection, 

25 with respect to medical assistance described in clause (4) 


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1 of such sentence that is furnished in Puerto Rico, the 

2 United States Virgin Islands, Guam, the Commonwealth 

3 of the Northern Mariana Islands, or American Samoa in 

4 a fiscal year, the Federal medical assistance percentage 

5 is equal to the highest such percentage applied under such 

6 clause for such fiscal year for any of the 50 States or the 

7 District of Columbia that provides such medical assistance 

8 for any portion of such fiscal year.’’ 

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

10 this section shall apply to payment for medical assistance 

11 for items and services furnished on or after October 1, 

12 2016. 

13 SEC. 704. CANCER PREVENTION AND TREATMENT DEM14 ONSTRATION FOR ETHNIC AND RACIAL MI15 NORITIES. 

16 (a) DEMONSTRATION.— 

17 (1) IN GENERAL.—The Secretary of Health and 

18 Human Services (in this section referred to as the 

19 ‘‘Secretary’’) shall conduct demonstration projects 

20 (in this section referred to as ‘‘demonstration 

21 projects’’) for the purpose of developing models and 

22 evaluating methods that— 

23 (A) improve the quality of items and serv24 ices provided to target individuals in order to 


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1 facilitate reduced disparities in early detection 

2 and treatment of cancer; 

3 (B) improve clinical outcomes, satisfaction, 

4 quality of life, appropriate use of items and 

5 services covered under the Medicare Program 

6 under title XVIII of the Social Security Act (42 

7 U.S.C. 1395 et seq.), and referral patterns with 

8 respect to target individuals with cancer; 

9 (C) eliminate disparities in the rate of pre10 ventive cancer screening measures, such as Pap 

11 smears, prostate cancer screenings, colon cancer 

12 screenings, breast cancer screenings, and com13 puted tomography (CT) scans, for lung cancer 

14 among target individuals; 

15 (D) promote collaboration with community16 based organizations to ensure cultural com17 petency of health care professionals and lin18 guistic access for target individuals who are 

19 persons with limited-English proficiency; and 

20 (E) encourage the incorporation of commu21 nity health workers to increase the efficiency 

22 and appropriateness of cancer screening pro23 grams. 

24 (2) COMMUNITY HEALTH WORKER DEFINED.— 

25 In this section, the term ‘‘community health worker’’ 


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1 includes a community health advocate, a lay health 

2 worker, a community health representative, a peer 

3 health promoter, a community health outreach work4 er, and a promotore de salud, who promotes health 

5 or nutrition within the community in which the indi6 vidual resides. 

7 (3) TARGET INDIVIDUAL DEFINED.—In this 

8 section, the term ‘‘target individual’’ means an indi9 vidual of a racial and ethnic minority group, as de10 fined in section 1707(g)(1) of the Public Health 

11 Service Act (42 U.S.C. 300u–6(g)(1)), who is enti12 tled to benefits under part A, and enrolled under 

13 part B, of title XVIII of the Social Security Act. 

14 (b) PROGRAM DESIGN.— 

15 (1) INITIAL DESIGN.—Not later than 1 year 

16 after the date of the enactment of this Act, the Sec17 retary shall evaluate best practices in the private 

18 sector, community programs, and academic research 

19 of methods that reduce disparities among individuals 

20 of racial and ethnic minority groups in the preven21 tion and treatment of cancer and shall design the 

22 demonstration projects based on such evaluation. 

23 (2) NUMBER AND PROJECT AREAS.—Not later 

24 than 2 years after the date of the enactment of this 


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1 Act, the Secretary shall implement at least nine 

2 demonstration projects, including the following: 

3 (A) Two projects, each of which shall tar4 get different ethnic subpopulations, for each of 

5 the four following major racial and ethnic mi6 nority groups: 

7 (i) American Indians and Alaska Na8 tives, Eskimos and Aleuts. 

9 (ii) Asian Americans. 

10 (iii) Blacks/African Americans. 

11 (iv) Latinos or Hispanics. 

12 (v) Native Hawaiians and other Pa13 cific Islanders. 

14 (B) One project within the Pacific Islands 

15 or United States insular areas. 

16 (C) At least one project each in a rural 

17 area and inner-city area. 

18 (3) EXPANSION OF PROJECTS; IMPLEMENTA19 TION OF DEMONSTRATION PROJECT RESULTS.—If 

20 the initial report under subsection (c) contains an 

21 evaluation that demonstration projects— 

22 (A) reduce expenditures under the Medi23 care Program under title XVIII of the Social 

24 Security Act (42 U.S.C. 1395 et seq.); or 


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1 (B) do not increase expenditures under the 

2 Medicare Program and reduce racial and ethnic 

3 health disparities in the quality of health care 

4 services provided to target individuals and in5 crease satisfaction of Medicare beneficiaries and 

6 health care providers; 

7 the Secretary shall continue the existing demonstra8 tion projects and may expand the number of dem9 onstration projects. 

10 (c) REPORT TO CONGRESS.— 

11 (1) IN GENERAL.—Not later than 2 years after 

12 the date the Secretary implements the initial dem13 onstration projects, and biannually thereafter, the 

14 Secretary shall submit to Congress a report regard15 ing the demonstration projects. 

16 (2) CONTENTS OF REPORT.—Each report under 

17 paragraph (1) shall include the following: 

18 (A) A description of the demonstration 

19 projects. 

20 (B) An evaluation of— 

21 (i) the cost-effectiveness of the dem22 onstration projects; 

23 (ii) the quality of the health care serv24 ices provided to target individuals under 

25 the demonstration projects; and 


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1 (iii) beneficiary and health care pro2 vider satisfaction under the demonstration 

3 projects. 

4 (C) Any other information regarding the 

5 demonstration projects that the Secretary de6 termines to be appropriate. 

7 (d) WAIVER AUTHORITY.—The Secretary shall waive 

8 compliance with the requirements of title XVIII of the So9 cial Security Act (42 U.S.C. 1395 et seq.) to such extent 

10 and for such period as the Secretary determines is nec11 essary to conduct demonstration projects. 

12 SEC. 705. REDUCING CANCER DISPARITIES WITHIN MEDI13 CARE. 

14 (a) DEVELOPMENT OF MEASURES OF DISPARITIES

15 IN QUALITY OF CANCER CARE.— 

16 (1) DEVELOPMENT OF MEASURES.—The Sec17 retary of Health and Human Services (in this sec18 tion referred to as the ‘‘Secretary’’) shall enter into 

19 an agreement with an entity that specializes in de20 veloping quality measures for cancer care under 

21 which the entity shall develop a uniform set of meas22 ures to evaluate disparities in the quality of cancer 

23 care and annually update such set of measures. 

24 (2) MEASURES TO BE INCLUDED.—Such set of 

25 measures shall include, with respect to the treatment 


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1 of cancer, measures of patient outcomes, the process 

2 for delivering medical care related to such treat3 ment, patient counseling and engagement in deci4 sionmaking, patient experience of care, resource use, 

5 and practice capabilities, such as care coordination. 

6 (b) ESTABLISHMENT OF REPORTING PROCESS.— 

7 (1) IN GENERAL.—The Secretary shall establish 

8 a reporting process that requires and provides for a 

9 method for health care providers specified under 

10 paragraph (2) to submit to the Secretary and make 

11 public data on the performance of such providers 

12 during each reporting period through use of the 

13 measures developed pursuant to subsection (a). Such 

14 data shall be submitted in a form and manner and 

15 at a time specified by the Secretary. 

16 (2) SPECIFICATION OF PROVIDERS TO REPORT

17 ON MEASURES.—The Secretary shall specify the 

18 classes of Medicare providers of services and sup19 pliers, including hospitals, cancer centers, physi20 cians, primary care providers, and specialty pro21 viders, that will be required under such process to 

22 publicly report on the measures specified under sub23 section (a). 

24 (3) ASSESSMENT OF CHANGES.—Under such 

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1 mat that assesses changes in both the absolute and 

2 relative disparities in cancer care over time. These 

3 measures shall be presented in an easily comprehen4 sible format, such as those presented in the final 

5 publications relating to Healthy People 2010 or the 

6 National Healthcare Disparities Report. 

7 (4) INITIAL IMPLEMENTATION.—The Secretary 

8 shall implement the reporting process under this 

9 subsection for reporting periods beginning not later 

10 than 6 months after the date that measures are first 

11 established under subsection (a). 

12 Subtitle B—Viral Hepatitis and 

13 Liver Cancer Control and Pre14 vention 

15 SEC. 711. VIRAL HEPATITIS AND LIVER CANCER CONTROL 

16 AND PREVENTION. 

17 (a) SHORT TITLE.—This subtitle may be cited as the 

18 ‘‘Viral Hepatitis and Liver Cancer Control and Prevention 

19 Act of 2018’’. 

20 (b) FINDINGS.—Congress finds the following: 

21 (1) In the United States, as many as 4,400,000 

22 persons are living with the hepatitis B virus (re23 ferred to in this section as ‘‘HBV’’) or the hepatitis 

24 C virus (referred to in this section as ‘‘HCV’’). 


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1 (2) In the United States, chronic HBV and 

2 HCV are the most common cause of liver cancer, 

3 one of the most lethal and fastest growing cancers 

4 in this country. It is the most common cause of 

5 chronic liver disease, liver cirrhosis, and the most 

6 common indication for liver transplantation. At least 

7 21,000 deaths per year in the United States can be 

8 attributed to chronic HBV and HCV. Chronic HCV 

9 is also a leading cause of death in Americans living 

10 with HIV/AIDS; many of those living with HIV/ 

11 AIDS are coinfected with chronic HBV, chronic 

12 HCV, or both. 

13 (3) According to the Centers for Disease Con14 trol and Prevention (referred to in this section as 

15 the ‘‘CDC’’), approximately 2 percent of the popu16 lation of the United States is living with chronic 

17 HBV, chronic HCV, or both. The CDC has recog18 nized HCV as the Nation’s most common chronic 

19 bloodborne virus infection and HBV as the deadliest 

20 vaccine-preventable disease. 

21 (4) HBV is easily transmitted and is 100 times 

22 more infectious than HIV. According to the CDC, 

23 HBV is transmitted through contact with infectious 

24 blood, semen, or other body fluids. HCV is trans25 mitted by contact with infectious blood, particularly 


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1 through percutaneous exposures (i.e. puncture 

2 through the skin). 

3 (5) The CDC estimates that in 2015, approxi4 mately 33,900 Americans were newly infected with 

5 HCV and approximately 21,900 Americans were 

6 newly infected with HBV. These estimates could be 

7 much higher due to many reasons, including lack of 

8 screening education and awareness, and perceived 

9 marginalization of the populations at risk. 

10 (6) In 2012, CDC released new guidelines rec11 ommending every person born between 1945 and 

12 1965 receive a one-time test. Among the estimated 

13 102 million (1.6 million chronically HCV-infected) 

14 eligible for screening, birth-cohort screening leads to 

15 84,000 fewer cases of decompensated cirrhosis, 

16 46,000 fewer cases of hepatocellular carcinoma, 

17 10,000 fewer liver transplants, and 78,000 fewer 

18 HCV-related deaths gained versus risk-based screen19 ing. 

20 (7) In 2013, the United States Preventive Serv21 ices Task Force (USPSTF) issued a Grade B rating 

22 for screening for the hepatitis C virus (HCV) infec23 tion in persons at high risk for infection and adults 

24 born between 1945 and 1965. In 2014, the 

25 USPSTF issued a Grade B for screening for the 


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1 hepatitis B virus (HBV) in persons at high-risk of 

2 hepatitis B infection. In 2009, the USPSTF issued 

3 a Grade A for screening pregnant women for the 

4 hepatitis B virus (HBV) during their first prenatal 

5 visit. 

6 (8) There were 59 outbreaks (24 of HBV and 

7 36 of HCV, including one of both HBV and HCV) 

8 reported to CDC for investigation from 2008 

9 through 2016 related to healthcare-associated infec10 tion of HBV and HCV, 56 of which occurred in non11 hospital settings. There were more than 115,983 pa12 tients potentially exposed to one of the viruses. 

13 (9) Chronic HBV and chronic HCV usually do 

14 not cause symptoms early in the course of the dis15 ease, but after many years of a clinically ‘‘silent’’ 

16 phase, CDC estimates show more than 33 percent of 

17 infected individuals will develop cirrhosis, end-stage 

18 liver disease, or liver cancer. Since most individuals 

19 with chronic HBV, HCV, or both are unaware of 

20 their infection, they do not know to take precautions 

21 to prevent the spread of their infection and can un22 knowingly exacerbate their own disease progression. 

23 (10) HBV and HCV disproportionately affect 

24 certain populations in the United States. Although 

25 representing only about 5 percent of the population, 


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1 Asian Americans and Pacific Islanders account for 

2 over half of all chronic HBV cases in the United 

3 States. Baby boomers (those born between 1945 and 

4 1965) account for approximately 75 percent of do5 mestic chronic hepatitis C cases. In addition, African 

6 Americans, Latinos (Latinas), and American Indian/ 

7 Native Alaskans are among the groups which have 

8 disproportionately high rates of HBV and/or HCV 

9 infections in the United States. 

10 (11) For both chronic HBV and chronic HCV, 

11 behavioral changes can slow disease progression if 

12 diagnosis is made early. Early diagnosis, which is 

13 determined through simple blood tests, can reduce 

14 the risk of transmission and disease progression 

15 through education and vaccination of household 

16 members and other susceptible persons at risk. 

17 (12) Advancements have led to the development 

18 of improved diagnostic tests for viral hepatitis. 

19 These tests, including rapid, point of care testing 

20 and others in development, can facilitate testing, no21 tification of results and post-test counseling, and re22 ferral to care at the time of the testing visit. In par23 ticular, these tests are also advantageous because 

24 they can be used simultaneously with HIV rapid 


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1 testing for persons at risk for both HCV and HIV 

2 infections. 

3 (13) For those chronically infected with HBV 

4 or HCV, regular monitoring can lead to the early de5 tection of liver cancer at a stage where a cure is still 

6 possible. Liver cancer is the second deadliest cancer 

7 in the United States; however, liver cancer has re8 ceived little funding for research, prevention, or 

9 treatment. 

10 (14) Treatment for chronic HCV can eradicate 

11 the disease in approximately 90 percent of those cur12 rently treated. The treatment of chronic HBV can 

13 effectively suppress viral replication in the over14 whelming majority (over 80 percent) of those treat15 ed, thereby reducing the risk of transmission and 

16 progression to liver scarring or liver cancer, even 

17 though a complete cure is much less common than 

18 for HCV. 

19 (15) To combat the viral hepatitis epidemic in 

20 the United States, in February 2017, the Depart21 ment of Health and Human Services released its 

22 ‘‘National Viral Hepatitis Action Plan 2017–2020’’ 

23 (hereafter referred to as the ‘‘HHS Action Plan’’). 

24 In March 2017, the National Academies of Sciences, 

25 Engineering, and Medicine (NASEM) released ‘‘A 


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1 National Strategy for the Elimination of Hepatitis B 

2 and C: Phase Two Report’’, recommending specific 

3 actions to eliminate viral hepatitis as public health 

4 problems in the United States by 2030. 

5 (16) The annual health care costs attributable 

6 to HBV and HCV in the United States are signifi7 cant. For HBV, it is estimated to be approximately 

8 $2,500,000,000 ($2,000 per infected person). In 

9 2000, the lifetime cost of HBV—before the avail10 ability of most current therapies—was approximately 

11 $80,000 per chronically infected person, totaling 

12 more than $100,000,000,000. For HCV, medical 

13 costs for patients are expected to increase from 

14 $30,000,000,000 in 2009 to over $85,000,000,000 

15 in 2024. Avoiding these costs by screening and diag16 nosing individuals earlier—and connecting them to 

17 appropriate treatment and care, will save lives and 

18 critical health care dollars. Currently, without a 

19 comprehensive screening, testing, and diagnosis pro20 gram, most patients are diagnosed too late when 

21 they need a liver transplant costing at least 

22 $314,000 for uncomplicated cases or when they have 

23 liver cancer or end-stage liver disease which costs 

24 $30,980 to $110,576 per hospital admission. As 

25 health care costs continue to grow, it is critical that 


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1 the Federal Government invests in effective mecha2 nisms to avoid documented cost drivers. 

3 (17) According to the IOM report in 2010, 

4 chronic HBV and HCV infections cause substantial 

5 morbidity and mortality despite being preventable 

6 and treatable. Deficiencies in the implementation of 

7 established guidelines for the prevention, diagnosis, 

8 and medical management of chronic HBV and HCV 

9 infections perpetuate personal and economic bur10 dens. Existing grants are not sufficient for the scale 

11 of the health burden presented by HBV and HCV. 

12 (18) Screening and testing for HBV and HCV 

13 is aligned with the Healthy People 2020 goal to in14 crease immunization rates and reduce preventable 

15 infectious diseases. Awareness of disease and access 

16 to prevention and treatment remain essential compo17 nents for reducing infectious disease transmission. 

18 (19) Federal support is necessary to increase 

19 knowledge and awareness of HBV and HCV and to 

20 assist State and local prevention and control efforts 

21 in reducing the morbidity and mortality of these 

22 epidemics. 

23 (20) The Secretary of Health and Human Serv24 ices has the discretion to carry out this Act directly 

25 and through whichever of the agencies of the Public 


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1 Health Service the Secretary determines to be ap2 propriate, which may (in the Secretary’s discretion) 

3 include the Centers for Disease Control and Preven4 tion, the Health Resources and Services Administra5 tion, the Substance Abuse and Mental Health Serv6 ices Administration, the National Institutes of 

7 Health (including the National Institute on Minority 

8 Health and Health Disparities), and other agencies 

9 of such Service. 

10 (21) The Centers for Disease Control and Pre11 vention reported a 151 percent increase in hepatitis 

12 C cases from 2010–2013, stemming from the opioid, 

13 heroin, and overdose epidemics affecting commu14 nities nationwide. For the first time since 2006, the 

15 number of reported cases of acute hepatitis B infec16 tion in the United States is rising; it increased by 

17 20.7 percent in 2015 alone, which is also largely due 

18 to the opioid epidemic. 

19 (c) BIENNIAL ASSESSMENT OF HHS HEPATITIS B 

20 AND HEPATITIS C PREVENTION, EDUCATION, RESEARCH, 

21 AND MEDICAL MANAGEMENT PLAN.—Title III of the 

22 Public Health Service Act (42 U.S.C. 241 et seq.) is 

23 amended— 

24 (1) by striking section 317N (42 U.S.C. 247b– 

25 15); and 


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

2 ‘‘PART X—BIENNIAL ASSESSMENT OF HHS HEPA3 TITIS B AND HEPATITIS C PREVENTION, EDU4 CATION, RESEARCH, AND MEDICAL MANAGE5 MENT PLAN 

6 ‘‘SEC. 399PP. BIENNIAL UPDATE OF THE PLAN. 

7 ‘‘(a) IN GENERAL.—The Secretary shall conduct a bi8 ennial assessment of the Secretary’s plan for the preven9 tion, control, and medical management of, and education 

10 and research relating to, hepatitis B and hepatitis C, for 

11 the purposes of— 

12 ‘‘(1) incorporating into such plan new knowl13 edge or observations relating to hepatitis B and hep14 atitis C (such as knowledge and observations that 

15 may be derived from clinical, laboratory, and epide16 miological research and disease detection, preven17 tion, and surveillance outcomes); 

18 ‘‘(2) addressing gaps in the coverage or effec19 tiveness of the plan; and 

20 ‘‘(3) evaluating and, if appropriate, updating 

21 recommendations, guidelines, or educational mate22 rials of the Centers for Disease Control and Preven23 tion or the National Institutes of Health for health 

24 care providers or the public on viral hepatitis in 

25 order to be consistent with the plan. 


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1 ‘‘(b) PUBLICATION OF NOTICE OF ASSESSMENTS.— 

2 Not later than October 1 of the first even-numbered year 

3 beginning after the date of the enactment of this part, 

4 and October 1 of each even-numbered year thereafter, the 

5 Secretary shall publish in the Federal Register a notice 

6 of the results of the assessments conducted under para7 graph (1). Such notice shall include— 

8 ‘‘(1) a description of any revisions to the plan 

9 referred to in subsection (a) as a result of the as10 sessment; 

11 ‘‘(2) an explanation of the basis for any such 

12 revisions, including the ways in which such revisions 

13 can reasonably be expected to further promote the 

14 original goals and objectives of the plan; and 

15 ‘‘(3) in the case of a determination by the Sec16 retary that the plan does not need revision, an expla17 nation of the basis for such determination. 

18 ‘‘SEC. 399PP–1. ELEMENTS OF PROGRAM. 

19 ‘‘(a) EDUCATION AND AWARENESS PROGRAMS.—The 

20 Secretary, acting through the Director of the Centers for 

21 Disease Control and Prevention, the Administrator of the 

22 Health Resources and Services Administration, and the 

23 Administrator of the Substance Abuse and Mental Health 

24 Services Administration, and in accordance with the plan 

25 referred to in section 399PP(a), shall implement programs 


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1 to increase awareness and enhance knowledge and under2 standing of hepatitis B and hepatitis C. Such programs 

3 shall include— 

4 ‘‘(1) the conduct of culturally and language ap5 propriate health education in primary and secondary 

6 schools, college campuses, public awareness cam7 paigns, and community outreach activities (especially 

8 to the ethnic communities with high rates of chronic 

9 hepatitis B and chronic hepatitis C and other high10 risk groups) to promote public awareness and knowl11 edge about the value of hepatitis A and hepatitis B 

12 immunization, risk factors, the transmission and 

13 prevention of hepatitis B and hepatitis C, the value 

14 of screening for the early detection of hepatitis B 

15 and hepatitis C, and options available for the treat16 ment of chronic hepatitis B and chronic hepatitis C; 

17 ‘‘(2) the promotion of immunization programs 

18 that increase awareness and access to hepatitis A 

19 and hepatitis B vaccines for susceptible adults and 

20 children; 

21 ‘‘(3) the training of health care professionals 

22 regarding the importance of vaccinating individuals 

23 infected with hepatitis C and individuals who are at 

24 risk for hepatitis C infection against hepatitis A and 

25 hepatitis B; 


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1 ‘‘(4) the training of health care professionals 

2 regarding the importance of vaccinating individuals 

3 chronically infected with hepatitis B and individuals 

4 who are at risk for chronic hepatitis B infection 

5 against the hepatitis A virus; 

6 ‘‘(5) the training of health care professionals 

7 and health educators to make them aware of the 

8 high rates of chronic hepatitis B and chronic hepa9 titis C in certain adult ethnic populations, and the 

10 importance of prevention, detection, and medical 

11 management of hepatitis B and hepatitis C and of 

12 liver cancer screening; 

13 ‘‘(6) the development and distribution of health 

14 education curricula (including information relating 

15 to the special needs of individuals infected with hep16 atitis B and hepatitis C, such as the importance of 

17 prevention and early intervention, regular moni18 toring, the recognition of psychosocial needs, appro19 priate treatment, and liver cancer screening) for in20 dividuals providing hepatitis B and hepatitis C coun21 seling; and 

22 ‘‘(7) support for the implementation curricula 

23 described in paragraph (6) by State and local public 

24 health agencies. 


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1 ‘‘(b) IMMUNIZATION, PREVENTION, AND CONTROL

2 PROGRAMS.— 

3 ‘‘(1) IN GENERAL.—The Secretary, acting 

4 through the Director of the Centers for Disease 

5 Control and Prevention, shall support the integra6 tion of activities described in paragraph (3) into ex7 isting clinical and public health programs at State, 

8 local, territorial, and Tribal levels (including commu9 nity health clinics, programs for the prevention and 

10 treatment of HIV/AIDS, sexually transmitted infec11 tions, and substance abuse, and programs for indi12 viduals in correctional settings). 

13 ‘‘(2) COORDINATION OF DEVELOPMENT OF

14 FEDERAL SCREENING GUIDELINES.— 

15 ‘‘(A) REFERENCES.—For purposes of this 

16 subsection, the term ‘CDC Director’ means the 

17 Director of the Centers for Disease Control and 

18 Prevention, and the term ‘AHRQ Director’ 

19 means the Director of the Agency for 

20 Healthcare Research and Quality. 

21 ‘‘(B) AGENCY FOR HEALTHCARE RE22 SEARCH AND QUALITY.—Due to the rapidly 

23 evolving standard of care associated with diag24 nosing and treating viral hepatitis infection, the 

25 AHRQ Director shall convene the Preventive 


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1 Services Task Force under section 915(a) of 

2 the Public Health Service Act to review its rec3 ommendation for screening for HBV and HCV 

4 infection every 3 years. 

5 ‘‘(3) ACTIVITIES.— 

6 ‘‘(A) VOLUNTARY TESTING PROGRAMS.— 

7 ‘‘(i) IN GENERAL.—The Secretary 

8 shall establish a mechanism by which to 

9 support and promote the development of 

10 State, local, territorial, and Tribal vol11 untary hepatitis B and hepatitis C testing 

12 programs to screen the high-prevalence 

13 populations to aid in the early identifica14 tion of chronically infected individuals. 

15 ‘‘(ii) CONFIDENTIALITY OF THE TEST

16 RESULTS.—The Secretary shall prohibit 

17 the use of the results of a hepatitis B or 

18 hepatitis C test conducted by a testing pro19 gram developed or supported under this 

20 subparagraph for any of the following: 

21 ‘‘(I) Issues relating to health in22 surance. 

23 ‘‘(II) To screen or determine 

24 suitability for employment. 


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1 ‘‘(III) To discharge a person 

2 from employment. 

3 ‘‘(B) COUNSELING REGARDING VIRAL HEP4 ATITIS.—The Secretary shall support State, 

5 local, territorial, and Tribal programs in a wide 

6 variety of settings, including those providing 

7 primary and specialty health care services in 

8 nonprofit private and public sectors, to— 

9 ‘‘(i) provide individuals with ongoing 

10 risk factors for hepatitis B and hepatitis C 

11 infection with client-centered education 

12 and counseling which concentrates on— 

13 ‘‘(I) promoting testing of individ14 uals that have been exposed to their 

15 blood, family members, and their sex16 ual partners; and 

17 ‘‘(II) changing behaviors that 

18 place individuals at risk for infection; 

19 ‘‘(ii) provide individuals chronically in20 fected with hepatitis B or hepatitis C with 

21 education, health information, and coun22 seling to reduce their risk of— 

23 ‘‘(I) dying from end-stage liver 

24 disease and liver cancer; and 


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1 ‘‘(II) transmitting viral hepatitis 

2 to others; and 

3 ‘‘(iii) provide women chronically in4 fected with hepatitis B or hepatitis C who 

5 are pregnant or of childbearing age with 

6 culturally and linguistically appropriate 

7 health information, such as how to prevent 

8 hepatitis B perinatal infection, and to al9 leviate fears associated with pregnancy or 

10 raising a family. 

11 ‘‘(C) IMMUNIZATION.—The Secretary shall 

12 support State, local, territorial, and Tribal ef13 forts to expand the current vaccination pro14 grams to protect every child in the country and 

15 all susceptible adults, particularly those infected 

16 with hepatitis C and high-prevalence ethnic 

17 populations and other high-risk groups, from 

18 the risks of acute and chronic hepatitis B infec19 tion by— 

20 ‘‘(i) ensuring continued funding for 

21 hepatitis B vaccination for all children 19 

22 years of age or younger through the Vac23 cines for Children Program; 

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1 nization Practices are followed regarding 

2 the birth dose of hepatitis B vaccinations 

3 for newborns; 

4 ‘‘(iii) requiring proof of hepatitis B 

5 vaccination for entry into public or private 

6 daycare, preschool, elementary school, sec7 ondary school, and institutions of higher 

8 education; 

9 ‘‘(iv) expanding the availability of 

10 hepatitis B vaccination for all susceptible 

11 adults to protect them from becoming 

12 acutely or chronically infected, including 

13 ethnic and other populations with high 

14 prevalence rates of chronic hepatitis B in15 fection; 

16 ‘‘(v) expanding the availability of hep17 atitis B vaccination for all susceptible 

18 adults, particularly those in their reproduc19 tive age (women and men less than 45 

20 years of age), to protect them from the 

21 risk of hepatitis B infection; 

22 ‘‘(vi) ensuring the vaccination of indi23 viduals infected, or at risk for infection, 

24 with hepatitis C against hepatitis A, hepa25 titis B, and other infectious diseases, as 


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1 appropriate, for which such individuals 

2 may be at increased risk; and 

3 ‘‘(vii) ensuring the vaccination of indi4 viduals infected, or at risk for infection, 

5 with hepatitis B against hepatitis A virus 

6 and other infectious diseases, as appro7 priate, for which such individuals may be 

8 at increased risk. 

9 ‘‘(D) MEDICAL REFERRAL.—The Secretary 

10 shall support State, local, territorial, and Tribal 

11 programs that support— 

12 ‘‘(i) referral of persons chronically in13 fected with hepatitis B or hepatitis C— 

14 ‘‘(I) for medical evaluation to de15 termine the appropriateness for 

16 antiviral treatment to reduce the risk 

17 of progression to cirrhosis and liver 

18 cancer; and 

19 ‘‘(II) for ongoing medical man20 agement including regular monitoring 

21 of liver function and screening for 

22 liver cancer; and 

23 ‘‘(ii) referral of persons infected with 

24 acute or chronic hepatitis B infection or 

25 acute or chronic hepatitis C infection for 


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1 drug and alcohol abuse treatment where 

2 appropriate. 

3 ‘‘(4) INCREASED SUPPORT FOR ADULT VIRAL

4 HEPATITIS PREVENTION COORDINATORS.—The Sec5 retary, acting through the Director of the Centers 

6 for Disease Control and Prevention, shall provide in7 creased support to adult viral hepatitis prevention 

8 coordinators in State, local, territorial, and Tribal 

9 health departments in order to enhance the addi10 tional management, networking, and technical exper11 tise needed to ensure successful integration of hepa12 titis B and hepatitis C prevention and control activi13 ties into existing public health programs. 

14 ‘‘(c) EPIDEMIOLOGICAL SURVEILLANCE.— 

15 ‘‘(1) IN GENERAL.—The Secretary, acting 

16 through the Director of the Centers for Disease 

17 Control and Prevention, shall support the establish18 ment and maintenance of a national chronic and 

19 acute hepatitis B and hepatitis C surveillance pro20 gram, in order to identify— 

21 ‘‘(A) trends in the incidence of acute and 

22 chronic hepatitis B and acute and chronic hepa23 titis C; 

24 ‘‘(B) trends in the prevalence of acute and 

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1 titis C infection among groups that may be dis2 proportionately affected; and 

3 ‘‘(C) trends in liver cancer and end-stage 

4 liver disease incidence and deaths, caused by 

5 chronic hepatitis B and chronic hepatitis C in 

6 the high-risk ethnic populations. 

7 ‘‘(2) SEROPREVALENCE AND LIVER CANCER

8 STUDIES.—The Secretary, acting through the Direc9 tor of the Centers for Disease Control and Preven10 tion, shall prepare a report outlining the population11 based seroprevalence studies currently underway, fu12 ture planned studies, the criteria involved in deter13 mining which seroprevalence studies to conduct, 

14 defer, or suspend, and the scope of those studies, the 

15 economic and clinical impact of hepatitis B and hep16 atitis C, and the impact of chronic hepatitis B and 

17 chronic hepatitis C infections on the quality of life. 

18 Not later than one year after the date of the enact19 ment of this part, the Secretary shall submit the re20 port to the Committee on Energy and Commerce of 

21 the House of Representatives and the Committee on 

22 Health, Education, Labor, and Pensions of the Sen23 ate. 

24 ‘‘(3) CONFIDENTIALITY.—The Secretary shall 

25 not disclose any individually identifiable information 


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1 identified under paragraph (1) or derived through 

2 studies under paragraph (2). 

3 ‘‘(d) RESEARCH.—The Secretary, acting through the 

4 Director of the Centers for Disease Control and Preven5 tion, the Director of the National Cancer Institute, and 

6 the Director of the National Institutes of Health, shall— 

7 ‘‘(1) conduct epidemiologic and community8 based research to develop, implement, and evaluate 

9 best practices for hepatitis B and hepatitis C pre10 vention especially in the ethnic populations with high 

11 rates of chronic hepatitis B and chronic hepatitis C 

12 and other high-risk groups; 

13 ‘‘(2) conduct research on hepatitis B and hepa14 titis C natural history, pathophysiology, improved 

15 treatments and prevention (such as the hepatitis C 

16 vaccine), and noninvasive tests that help to predict 

17 the risk of progression to liver cirrhosis and liver 

18 cancer; 

19 ‘‘(3) conduct research that will lead to better 

20 noninvasive or blood tests to screen for liver cancer, 

21 and more effective treatments of liver cancer caused 

22 by chronic hepatitis B and chronic hepatitis C; and 

23 ‘‘(4) conduct research comparing the effective24 ness of screening, diagnostic, management, and 

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1 ic hepatitis C, and liver cancer in the affected com2 munities. 

3 ‘‘(e) UNDERSERVED AND DISPROPORTIONATELY AF4 FECTED POPULATIONS.—In carrying out this section, the 

5 Secretary shall provide expanded support for individuals 

6 with limited access to health education, testing, and health 

7 care services and groups that may be disproportionately 

8 affected by hepatitis B and hepatitis C. 

9 ‘‘(f) EVALUATION OF PROGRAM.—The Secretary 

10 shall develop benchmarks for evaluating the effectiveness 

11 of the programs and activities conducted under this sec12 tion and make determinations as to whether such bench13 marks have been achieved. 

14 ‘‘SEC. 399PP–2. GRANTS. 

15 ‘‘(a) IN GENERAL.—The Secretary may award grants 

16 to, or enter into contracts or cooperative agreements with, 

17 States, political subdivisions of States, territories, Indian 

18 Tribes, or nonprofit entities that have special expertise re19 lating to hepatitis B, hepatitis C, or both, to carry out 

20 activities under this part. 

21 ‘‘(b) APPLICATION.—To be eligible for a grant, con22 tract, or cooperative agreement under subsection (a), an 

23 entity shall prepare and submit to the Secretary an appli24 cation at such time, in such manner, and containing such 

25 information as the Secretary may require. 


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1 ‘‘SEC. 399PP–3. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated to carry out 

3 this part $90,000,000 for fiscal year 2019, $90,000,000 

4 for fiscal year 2020, $110,000,000 for fiscal year 2021, 

5 $130,000,000 for fiscal year 2022, and $150,000,000 for 

6 fiscal year 2023.’’. 

7 Subtitle C—Acquired Bone Marrow 

8 Failure Diseases 

9 SEC. 721. ACQUIRED BONE MARROW FAILURE DISEASES. 

10 (a) SHORT TITLE.—This subtitle may be cited as the 

11 ‘‘Bone Marrow Failure Disease Research and Treatment 

12 Act of 2018’’. 

13 (b) FINDINGS.—The Congress finds the following: 

14 (1) Between 20,000 and 30,000 Americans are 

15 diagnosed each year with myelodysplastic syndromes, 

16 aplastic anemia, paroxysmal nocturnal hemo17 globinuria, and other acquired bone marrow failure 

18 diseases. 

19 (2) Acquired bone marrow failure diseases have 

20 a debilitating and often fatal impact on those diag21 nosed with these diseases. 

22 (3) While some treatments for acquired bone 

23 marrow failure diseases can prolong and improve the 

24 quality of patients’ lives, there is no single cure for 

25 these diseases. 


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1 (4) The prevalence of acquired bone marrow 

2 failure diseases in the United States will continue to 

3 grow as the general public ages. 

4 (5) Evidence exists suggesting that acquired 

5 bone marrow failure diseases occur more often in 

6 minority populations, particularly in Asian-American 

7 and Latino or Hispanic populations. 

8 (6) The National Heart, Lung, and Blood Insti9 tute and the National Cancer Institute have con10 ducted important research into the causes of and 

11 treatments for acquired bone marrow failure dis12 eases. 

13 (7) The National Marrow Donor Program Reg14 istry has made significant contributions to the fight 

15 against bone marrow failure diseases by connecting 

16 millions of potential marrow donors with individuals 

17 and families suffering from these conditions. 

18 (8) Despite these advances, a more comprehen19 sive Federal strategic effort among numerous Fed20 eral agencies is needed to discover a cure for ac21 quired bone marrow failure disorders. 

22 (9) Greater Federal surveillance of acquired 

23 bone marrow failure diseases is needed to gain a bet24 ter understanding of the causes of acquired bone 

25 marrow failure diseases. 


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1 (10) The Federal Government should increase 

2 its research support for and engage with public and 

3 private organizations in developing a comprehensive 

4 approach to combat and cure acquired bone marrow 

5 failure diseases. 

6 (c) NATIONAL ACQUIRED BONE MARROW FAILURE

7 DISEASE REGISTRY.—Part B of the Public Health Service 

8 Act (42 U.S.C. 311 et seq.) is amended by inserting after 

9 section 317W, as added, the following: 

10 ‘‘SEC. 317X. NATIONAL ACQUIRED BONE MARROW FAILURE 

11 DISEASE REGISTRY. 

12 ‘‘(a) ESTABLISHMENT OF REGISTRY.— 

13 ‘‘(1) IN GENERAL.—Not later than 6 months 

14 after the date of the enactment of this section, the 

15 Secretary, acting through the Director of the Cen16 ters for Disease Control and Prevention, shall— 

17 ‘‘(A) develop a system to collect data on 

18 acquired bone marrow failure diseases; and 

19 ‘‘(B) establish and maintain a national and 

20 publicly available registry, to be known as the 

21 National Acquired Bone Marrow Failure Dis22 ease Registry, in accordance with paragraph 

23 (3). 

24 ‘‘(2) RECOMMENDATIONS OF ADVISORY COM25 MITTEE.—In carrying out this subsection, the SecVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00557 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 retary shall take into consideration the recommenda2 tions of the Advisory Committee on Acquired Bone 

3 Marrow Failure Diseases established under sub4 section (b). 

5 ‘‘(3) PURPOSES OF REGISTRY.—The National 

6 Acquired Bone Marrow Failure Disease Registry— 

7 ‘‘(A) shall identify the incidence and preva8 lence of acquired bone marrow failure diseases 

9 in the United States; 

10 ‘‘(B) shall be used to collect and store data 

11 on acquired bone marrow failure diseases, in12 cluding data concerning— 

13 ‘‘(i) the age, race or ethnicity, general 

14 geographic location, sex, and family history 

15 of individuals who are diagnosed with ac16 quired bone marrow failure diseases, and 

17 any other characteristics of such individ18 uals determined appropriate by the Sec19 retary; 

20 ‘‘(ii) the genetic and environmental 

21 factors that may be associated with devel22 oping acquired bone marrow failure dis23 eases; 


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1 ‘‘(iii) treatment approaches for deal2 ing with acquired bone marrow failure dis3 eases; 

4 ‘‘(iv) outcomes for individuals treated 

5 for acquired bone marrow failure diseases, 

6 including outcomes for recipients of stem 

7 cell therapeutic products as contained in 

8 the database established pursuant to sec9 tion 379A; and 

10 ‘‘(v) any other factors pertaining to 

11 acquired bone marrow failure diseases de12 termined appropriate by the Secretary; and 

13 ‘‘(C) shall be made available— 

14 ‘‘(i) to the general public; and 

15 ‘‘(ii) to researchers to facilitate fur16 ther research into the causes of, and treat17 ments for, acquired bone marrow failure 

18 diseases in accordance with standard prac19 tices of the Centers for Disease Control 

20 and Preventions. 

21 ‘‘(b) ADVISORY COMMITTEE.— 

22 ‘‘(1) ESTABLISHMENT.—Not later than 6 

23 months after the date of the enactment of this sec24 tion, the Secretary, acting through the Director of 

25 the Centers for Disease Control and Prevention, 


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1 shall establish an advisory committee, to be known 

2 as the Advisory Committee on Acquired Bone Mar3 row Failure Diseases. 

4 ‘‘(2) MEMBERS.—The members of the Advisory 

5 Committee on Acquired Bone Marrow Failure Dis6 eases shall be appointed by the Secretary, acting 

7 through the Director of the Centers for Disease 

8 Control and Prevention, and shall include at least 

9 one representative from each of the following: 

10 ‘‘(A) A national patient advocacy organiza11 tion with experience advocating on behalf of pa12 tients suffering from acquired bone marrow 

13 failure diseases. 

14 ‘‘(B) The National Institutes of Health, in15 cluding at least one representative from each 

16 of— 

17 ‘‘(i) the National Cancer Institute; 

18 ‘‘(ii) the National Heart, Lung, and 

19 Blood Institute; and 

20 ‘‘(iii) the Office of Rare Diseases. 

21 ‘‘(C) The Centers for Disease Control and 

22 Prevention. 

23 ‘‘(D) Clinicians with experience in— 

24 ‘‘(i) diagnosing or treating acquired 

25 bone marrow failure diseases; and 


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1 ‘‘(ii) medical data registries. 

2 ‘‘(E) Epidemiologists who have experience 

3 with data registries. 

4 ‘‘(F) Publicly or privately funded research5 ers who have experience researching acquired 

6 bone marrow failure diseases. 

7 ‘‘(G) The entity operating the C.W. Bill 

8 Young Cell Transplantation Program estab9 lished pursuant to section 379 and the entity 

10 operating the C.W. Bill Young Cell Transplan11 tation Program Outcomes Database. 

12 ‘‘(3) RESPONSIBILITIES.—The Advisory Com13 mittee on Acquired Bone Marrow Failure Diseases 

14 shall provide recommendations to the Secretary on 

15 the establishment and maintenance of the National 

16 Acquired Bone Marrow Failure Disease Registry, in17 cluding recommendations on the collection, mainte18 nance, and dissemination of data. 

19 ‘‘(4) PUBLIC AVAILABILITY.—The Secretary 

20 shall make the recommendations of the Advisory 

21 Committee on Acquired Bone Marrow Failure Dis22 ease publicly available. 

23 ‘‘(c) GRANTS.—The Secretary, acting through the 

24 Director of the Centers for Disease Control and Preven25 tion, may award grants to, and enter into contracts and 


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1 cooperative agreements with, public or private nonprofit 

2 entities for the management of, as well as the collection, 

3 analysis, and reporting of data to be included in, the Na4 tional Acquired Bone Marrow Failure Disease Registry. 

5 ‘‘(d) DEFINITION.—In this section, the term ‘ac6 quired bone marrow failure disease’ means— 

7 ‘‘(1) myelodysplastic syndromes (MDS); 

8 ‘‘(2) aplastic anemia; 

9 ‘‘(3) paroxysmal nocturnal hemoglobinuria 

10 (PNH); 

11 ‘‘(4) pure red cell aplasia; 

12 ‘‘(5) acute myeloid leukemia that has pro13 gressed from myelodysplastic syndromes; or 

14 ‘‘(6) large granular lymphocytic leukemia. 

15 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

16 is authorized to be appropriated to carry out this section 

17 $3,000,000 for each of fiscal years 2019 through 2023.’’. 

18 (d) PILOT STUDIES THROUGH THE AGENCY FOR

19 TOXIC SUBSTANCES AND DISEASE REGISTRY.— 

20 (1) PILOT STUDIES.—The Secretary of Health 

21 and Human Services, acting through the Adminis22 trator of the Agency for Toxic Substances and Dis23 ease Registry, shall conduct pilot studies to deter24 mine which environmental factors, including expoVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00562 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 sure to toxins, may cause acquired bone marrow fail2 ure diseases. 

3 (2) COLLABORATION WITH THE RADIATION IN4 JURY TREATMENT NETWORK.—In carrying out the 

5 directives of this section, the Secretary may collabo6 rate with the Radiation Injury Treatment Network 

7 of the C.W. Bill Young Cell Transplantation Pro8 gram established pursuant to section 379 of the 

9 Public Health Service Act (42 U.S.C. 274j) to— 

10 (A) augment data for the pilot studies au11 thorized by this section; 

12 (B) access technical assistance that may be 

13 provided by the Radiation Injury Treatment 

14 Network; or 

15 (C) perform joint research projects. 

16 (3) AUTHORIZATION OF APPROPRIATIONS.— 

17 There is authorized to be appropriated to carry out 

18 this section $1,000,000 for each of fiscal years 2019 

19 through 2023. 

20 (e) MINORITY-FOCUSED PROGRAMS ON ACQUIRED

21 BONE MARROW FAILURE DISEASES.—Title XVII of the 

22 Public Health Service Act (42 U.S.C. 300u et seq.) is 

23 amended by inserting after section 1707A the following: 


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1 ‘‘MINORITY-FOCUSED PROGRAMS ON ACQUIRED BONE

2 MARROW FAILURE DISEASES

3 ‘‘SEC. 1707B. (a) INFORMATION AND REFERRAL

4 SERVICES.— 

5 ‘‘(1) IN GENERAL.—Not later than 6 months 

6 after the date of the enactment of this section, the 

7 Secretary, acting through the Deputy Assistant Sec8 retary for Minority Health, shall establish and co9 ordinate outreach and informational programs tar10 geted to minority populations affected by acquired 

11 bone marrow failure diseases. 

12 ‘‘(2) PROGRAM REQUIREMENTS.—Minority-fo13 cused outreach and informational programs author14 ized by this section— 

15 ‘‘(A) shall make information about treat16 ment options and clinical trials for acquired 

17 bone marrow failure diseases publicly available; 

18 and 

19 ‘‘(B) shall provide referral services for 

20 treatment options and clinical trials; 

21 at the National Minority Health Resource Center 

22 supported under section 1707(b)(8) (including by 

23 means of the Center’s website, through appropriate 

24 locations such as the Center’s knowledge center, and 

25 through appropriate programs such as the Center’s 


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1 resource persons network) and through minority 

2 health consultants located at each Department of 

3 Health and Human Services regional office. 

4 ‘‘(b) HISPANIC AND ASIAN-AMERICAN AND PACIFIC

5 ISLANDER OUTREACH.— 

6 ‘‘(1) IN GENERAL.—The Secretary, acting 

7 through the Deputy Assistant Secretary for Minority 

8 Health, shall undertake a coordinated outreach ef9 fort to connect Hispanic, Asian-American, and Pa10 cific Islander communities with comprehensive serv11 ices focused on treatment of, and information about, 

12 acquired bone marrow failure diseases. 

13 ‘‘(2) COLLABORATION.—In carrying out this 

14 subsection, the Secretary may collaborate with public 

15 health agencies, nonprofit organizations, community 

16 groups, and online entities to disseminate informa17 tion about treatment options and clinical trials for 

18 acquired bone marrow failure diseases. 

19 ‘‘(c) GRANTS AND COOPERATIVE AGREEMENTS.— 

20 ‘‘(1) IN GENERAL.—Not later than 6 months 

21 after the date of the enactment of this section, the 

22 Secretary, acting through the Deputy Assistant Sec23 retary for Minority Health, shall award grants to, or 

24 enter into cooperative agreements with, entities to 


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1 perform research on acquired bone marrow failure 

2 diseases. 

3 ‘‘(2) REQUIREMENT.—Grants and cooperative 

4 agreements authorized by this subsection shall be 

5 awarded or entered into on a competitive, peer-re6 viewed basis. 

7 ‘‘(3) SCOPE OF RESEARCH.—Research funded 

8 under this section shall examine factors affecting the 

9 incidence of acquired bone marrow failure diseases 

10 in minority populations. 

11 ‘‘(d) DEFINITION.—In this section, the term ‘ac12 quired bone marrow failure disease’ has the meaning given 

13 to such term in section 317X(d). 

14 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

15 is authorized to be appropriated to carry out this section 

16 $2,000,000 for each of fiscal years 2019 through 2023.’’. 

17 (f) DIAGNOSIS AND QUALITY OF CARE FOR AC18 QUIRED BONE MARROW FAILURE DISEASES.— 

19 (1) GRANTS.—The Secretary of Health and 

20 Human Services, acting through the Director of the 

21 Agency for Healthcare Research and Quality, shall 

22 award grants to entities to improve diagnostic prac23 tices and quality of care with respect to patients 

24 with acquired bone marrow failure diseases. 


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1 (2) AUTHORIZATION OF APPROPRIATIONS.— 

2 There is authorized to be appropriated to carry out 

3 this section $2,000,000 for each of fiscal years 2019 

4 through 2023. 

5 (g) DEFINITION.—In this section, the term ‘‘acquired 

6 bone marrow failure disease’’ means— 

7 (1) myelodysplastic syndromes (MDS); 

8 (2) aplastic anemia; 

9 (3) paroxysmal nocturnal hemoglobinuria 

10 (PNH); 

11 (4) pure red cell aplasia; 

12 (5) acute myeloid leukemia that progressed 

13 from myelodysplastic syndromes; or 

14 (6) large granular lymphocytic leukemia. 

15 Subtitle D—Cardiovascular Dis16 ease, Chronic Disease, and 

17 Other Disease Issues 

18 SEC. 731. GUIDELINES FOR DISEASE SCREENING FOR MI19 NORITY PATIENTS. 

20 (a) IN GENERAL.—The Secretary, acting through the 

21 Director of the Agency for Healthcare Research and Qual22 ity, shall convene a series of meetings to develop guidelines 

23 for disease screening for minority patient populations 

24 which have a higher than average risk for many chronic 

25 diseases and cancers. 


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1 (b) PARTICIPANTS.—In convening meetings under 

2 subsection (a), the Secretary shall ensure that meeting 

3 participants include representatives of— 

4 (1) professional societies and associations; 

5 (2) minority health organizations; 

6 (3) health care researchers and providers, in7 cluding those with expertise in minority health; 

8 (4) Federal health agencies, including the Of9 fice of Minority Health, the National Institute on 

10 Minority Health and Health Disparities, and the 

11 National Institutes of Health; and 

12 (5) other experts determined appropriate by the 

13 Secretary. 

14 (c) DISEASES.—Screening guidelines for minority 

15 populations shall be developed as appropriate under sub16 section (a) for— 

17 (1) hypertension; 

18 (2) hypercholesterolemia; 

19 (3) diabetes; 

20 (4) cardiovascular disease; 

21 (5) cancers, including breast, prostate, colon, 

22 cervical, and lung cancer; 

23 (6) other pulmonary problems including sleep 

24 apnea; 

25 (7) asthma; 


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1 (8) diabetes; 

2 (9) kidney diseases; 

3 (10) eye diseases and disorders, including glau4 coma; 

5 (11) HIV/AIDS and sexually transmitted infec6 tions; 

7 (12) uterine fibroids; 

8 (13) autoimmune disease; 

9 (14) mental health conditions; 

10 (15) dental health conditions and oral diseases, 

11 including oral cancer; 

12 (16) environmental and related health illnesses 

13 and conditions; 

14 (17) sickle cell disease and sickle cell trait; 

15 (18) violence and injury prevention and control; 

16 (19) genetic and related conditions; 

17 (20) heart disease and stroke; 

18 (21) tuberculosis; 

19 (22) chronic obstructive pulmonary disease; 

20 (23) musculoskeletal diseases, arthritis, and 

21 obesity; and 

22 (24) other diseases determined appropriate by 

23 the Secretary. 

24 (d) DISSEMINATION.—Not later than 24 months 

25 after the date of enactment of this title, the Secretary 


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1 shall publish and disseminate to health care provider orga2 nizations the guidelines developed under subsection (a). 

3 (e) AUTHORIZATION OF APPROPRIATIONS.—There 

4 are authorized to be appropriated to carry out this section 

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

6 2019 through 2023. 

7 SEC. 732. CDC WISEWOMAN SCREENING PROGRAM. 

8 Section 1509 of the Public Health Service Act (42 

9 U.S.C. 300n–4a) is amended— 

10 (1) in subsection (a)— 

11 (A) by striking the heading and inserting 

12 ‘‘IN GENERAL.—’’; and 

13 (B) in the matter preceding paragraph (1), 

14 by striking ‘‘may make grants’’ and all that fol15 lows through ‘‘purpose’’ and inserting the fol16 lowing: ‘‘may make grants to such States for 

17 the purpose’’; and 

18 (2) in subsection (d)(1), by striking ‘‘there are 

19 authorized’’ and all that follows through the period 

20 and inserting ‘‘there are authorized to be appro21 priated $23,000,000 for fiscal year 2019, 

22 $25,300,000 for fiscal year 2020, $27,800,000 for 

23 fiscal year 2021, $30,800,000 for fiscal year 2022, 

24 and $34,000,000 for fiscal year 2023.’’. 


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1 SEC. 733. REPORT ON CARDIOVASCULAR CARE FOR WOMEN 

2 AND MINORITIES. 

3 Part P of title III of the Public Health Service Act 

4 (42 U.S.C. 280g et seq.), as amended, is further amended 

5 by adding at the end the following: 

6 ‘‘SEC. 399V–8. REPORT ON CARDIOVASCULAR CARE FOR 

7 WOMEN AND MINORITIES. 

8 ‘‘Not later than September 30, 2019, and annually 

9 thereafter, the Secretary shall prepare and submit to the 

10 Congress a report on the quality of and access to care 

11 for women and minorities with heart disease, stroke, and 

12 other cardiovascular diseases. The report shall contain rec13 ommendations for eliminating disparities in, and improv14 ing the treatment of, heart disease, stroke, and other car15 diovascular diseases in women, racial and ethnic minori16 ties, those for whom English is not their primary lan17 guage, and individuals with disabilities.’’. 

18 SEC. 734. COVERAGE OF COMPREHENSIVE TOBACCO CES19 SATION SERVICES IN MEDICAID AND PRI20 VATE HEALTH INSURANCE. 

21 (a) REQUIRING MEDICAID COVERAGE OF COUN22 SELING AND PHARMACOTHERAPY FOR CESSATION OF TO23 BACCO USE.—Section 1905 of the Social Security Act (42 

24 U.S.C. 1396d) is amended— 

25 (1) in subsection (a)(4)(D), by striking ‘‘by 

26 pregnant women’’; and 


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1 (2) in subsection (bb)— 

2 (A) by striking ‘‘by pregnant women’’ each 

3 place it appears; 

4 (B) in paragraph (1), in the matter before 

5 subparagraph (A), by inserting ‘‘by individuals’’ 

6 before ‘‘who use tobacco’’; and 

7 (C) in paragraph (2)(A), by striking ‘‘with 

8 respect to pregnant women’’. 

9 (b) EXCEPTION FROM OPTIONAL RESTRICTION

10 UNDER MEDICAID PRESCRIPTION DRUG COVERAGE.— 

11 Section 1927(d)(2)(F) of the Social Security Act (42 

12 U.S.C. 1396r–8(d)(2)(F)) is amended— 

13 (1) by striking ‘‘in the case of pregnant 

14 women’’; and 

15 (2) by striking ‘‘under the over-the-counter 

16 monograph process’’. 

17 (c) STATE MONITORING AND PROMOTING OF COM18 PREHENSIVE TOBACCO CESSATION SERVICES UNDER

19 MEDICAID.—Section 1902(a) of the Social Security Act 

20 (42 U.S.C. 1396a(a)), as amended by section 450(c), is 

21 amended— 

22 (1) by striking ‘‘and’’ at the end of paragraph 

23 (82); 

24 (2) by striking the period at the end of para25 graph (83) and inserting ‘‘; and’’; and 


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1 (3) by inserting after paragraph (83) the fol2 lowing new paragraph: 

3 ‘‘(84) provide for the State to monitor and pro4 mote the use of comprehensive tobacco cessation 

5 services under the State plan, including conducting 

6 an outreach campaign to increase awareness of, and 

7 the benefits of using, such services among— 

8 ‘‘(A) individuals entitled to medical assist9 ance under the State plan who use tobacco 

10 products; and 

11 ‘‘(B) clinicians and others who provide 

12 services to individuals entitled to medical assist13 ance under the State plan.’’. 

14 (d) FEDERAL REIMBURSEMENT FOR MEDICAID OUT15 REACH CAMPAIGN TO INCREASE AWARENESS.—Section 

16 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) 

17 is amended— 

18 (1) by striking the period at the end of para19 graph (7) and inserting ‘‘; plus’’; and 

20 (2) by inserting after paragraph (7) the fol21 lowing new paragraph: 

22 ‘‘(8) an amount equal to 90 percent of the 

23 sums expended during each quarter which are attrib24 utable to the development, implementation, and eval25 uation of an outreach campaign to— 


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1 ‘‘(A) increase awareness of comprehensive 

2 tobacco cessation services covered in the State 

3 plan among— 

4 ‘‘(i) individuals who are likely to be el5 igible for medical assistance under the 

6 State plan; and 

7 ‘‘(ii) clinicians and others who provide 

8 services to individuals who are likely to be 

9 eligible for medical assistance under the 

10 State plan; and 

11 ‘‘(B) increase awareness of the benefits of 

12 using comprehensive tobacco cessation services 

13 covered in the State plan among— 

14 ‘‘(i) individuals who are likely to be el15 igible for medical assistance under the 

16 State plan; and 

17 ‘‘(ii) clinicians and others who provide 

18 services to individuals who are likely to be 

19 eligible for medical assistance under the 

20 State plan about the benefits of using com21 prehensive tobacco cessation services.’’. 

22 (e) REMOVAL OF COST SHARING FOR COUNSELING

23 AND PHARMACOTHERAPY FOR CESSATION OF TOBACCO

24 USE UNDER MEDICAID.— 


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1 (1) GENERAL COST SHARING LIMITATIONS.— 

2 Section 1916 of the Social Security Act (42 U.S.C. 

3 1396o) is amended— 

4 (A) in subsections (a)(2)(B) and (b)(2)(B), 

5 by striking ‘‘and counseling and 

6 pharmacotherapy for cessation of tobacco use 

7 by pregnant women (as defined in section 

8 1396d(bb) of this title) and covered outpatient 

9 drugs (as defined in subsection (k)(2) of section 

10 1396r–8 of this title and including nonprescrip11 tion drugs described in subsection (d)(2) of 

12 such section) that are prescribed for purposes 

13 of promoting, and when used to promote, to14 bacco cessation by pregnant women in accord15 ance with the Guideline referred to in section 

16 1396d(bb)(2)(A) of this title’’ each place it ap17 pears; and 

18 (B) in each of subsections (a)(2)(D) and 

19 (b)(2)(D) by inserting ‘‘and counseling and 

20 pharmacotherapy for cessation of tobacco use 

21 (as defined in section 1396d(bb) of this title) 

22 and covered outpatient drugs (as defined in 

23 subsection (k)(2) of section 1396r–8 of this 

24 title and including nonprescription drugs de25 scribed in subsection (d)(2) of such section) 


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1 that are prescribed for purposes of promoting, 

2 and when used to promote, tobacco cessation in 

3 accordance with the Guideline referred to in 

4 section 1396d(bb)(2)(A) of this title,’’ after 

5 ‘‘(or at the option of the State, any services fur6 nished to pregnant women’’. 

7 (2) APPLICATION TO ALTERNATIVE COST SHAR8 ING.—Section 1916A(b)(3)(B) of such Act (42 

9 U.S.C. 1396o–1(b)(3)(B)) is amended— 

10 (A) in clause (iii), by striking ‘‘, and coun11 seling and pharmacotherapy for cessation of to12 bacco use by pregnant women (as defined in 

13 section 1396d of this title)’’; and 

14 (B) by adding at the end the following: 

15 ‘‘(xi) Counseling and 

16 pharmacotherapy for cessation of tobacco 

17 use (as defined in section 1905(bb)) and 

18 covered outpatient drugs (as defined in 

19 subsection (k)(2) of section 1396r–8 of 

20 this title and including nonprescription 

21 drugs described in subsection (d)(2) of 

22 such section) that are prescribed for pur23 poses of promoting, and when used to pro24 mote, tobacco cessation in accordance with 


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1 the Guideline referred to in section 1396d 

2 (bb)(2)(A) of this title.’’. 

3 (f) NO PRIOR AUTHORIZATION FOR TOBACCO CES4 SATION DRUGS UNDER MEDICAID.—Section 1927(d) of 

5 the Social Security Act (42 U.S.C. 1396r–8) is amended— 

6 (1) by striking in paragraph (1)(A) ‘‘A State’’ 

7 and inserting ‘‘Except as otherwise provided in para8 graph (6), a State’’; 

9 (2) by inserting after paragraph (5) the fol10 lowing new paragraph: 

11 ‘‘(6) NO PRIOR AUTHORIZATION PROGRAMS FOR

12 TOBACCO CESSATION DRUGS.—A State plan under 

13 this subchapter shall not require, as a condition of 

14 coverage or payment for a covered outpatient drug 

15 for which Federal financial participation is available 

16 in accordance with this section, the approval of an 

17 agent when used to promote smoking cessation, in18 cluding agents approved by the Food and Drug Ad19 ministration for the purposes of promoting, and 

20 when used to promote, tobacco cessation.’’. 

21 (3) by redesignating paragraphs (6) and (7) as 

22 paragraphs (7) and (8). 

23 (g) COMPREHENSIVE COVERAGE OF TOBACCO CES24 SATION COVERAGE IN PRIVATE HEALTH INSURANCE.— 


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1 (1) NO PRIOR AUTHORIZATION FOR TOBACCO

2 CESSATION COVERAGE.—Section 2713 of the Public 

3 Health Service Act (42 U.S.C. 300gg–3) is amended 

4 by inserting after subsection (c) a new subsection: 

5 ‘‘(d) NO PRIOR AUTHORIZATION.—A group health 

6 plan and a health insurance issuer offering group or indi7 vidual health insurance coverage shall not impose any 

8 prior authorization requirement for tobacco cessation 

9 counseling and pharmacotherapy that has in effect a rat10 ing of ‘A’ or ‘B’ in the current recommendations of the 

11 United States Preventive Services Task Force.’’. 

12 (2) NO COST SHARING.—Section 1302(c) of the 

13 Patient Protection and Affordable Care Act (42 

14 U.S.C. 18022(c)) is amended by inserting after 

15 paragraph (1) the following new paragraph: 

16 ‘‘(2) NO COST SHARING OR PRIOR AUTHORIZA17 TION FOR COMPREHENSIVE TOBACCO CESSATION

18 COVERAGE.—There shall be no cost sharing or prior 

19 authorization requirement imposed with respect to 

20 services described in subsection (b)(1)(K).’’. 

21 (h) EFFECTIVE DATE.—The amendments made by 

22 this section shall apply to items and services furnished on 

23 or after January 1, 2019. 


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1 SEC. 735. CLINICAL RESEARCH FUNDING FOR ORAL 

2 HEALTH. 

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

4 Human Services shall expand and intensify the conduct 

5 and support of the research activities of the National In6 stitutes of Health and the National Institute of Dental 

7 and Craniofacial Research to improve the oral health of 

8 the population through the prevention and management 

9 of oral diseases and conditions. 

10 (b) INCLUDED RESEARCH ACTIVITIES.—Research 

11 activities under subsection (a) shall include— 

12 (1) comparative effectiveness research and clin13 ical disease management research addressing early 

14 childhood caries and oral cancer; and 

15 (2) awarding of grants and contracts to support 

16 the training and development of health services re17 searchers, comparative effectiveness researchers, and 

18 clinical researchers whose research improves the oral 

19 health of the population. 

20 SEC. 736. PARTICIPATION BY MEDICAID BENEFICIARIES IN 

21 APPROVED CLINICAL TRIALS. 

22 (a) IN GENERAL.—Title XIX of the Social Security 

23 Act (42 U.S.C. 1396 et seq.) is amended by inserting after 

24 section 1943 the following new section: 


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1 ‘‘SEC. 1944. PARTICIPATION IN AN APPROVED CLINICAL 

2 TRIAL. 

3 ‘‘(a) COVERAGE OF ROUTINE PATIENT COSTS ASSO4 CIATED WITH APPROVED CLINICAL TRIALS.— 

5 ‘‘(1) INCLUSION.—Subject to paragraph (2), 

6 routine patient costs shall include all items and serv7 ices consistent with the medical assistance provided 

8 under the State plan that would otherwise be pro9 vided to the individual under such State plan if such 

10 individual was not enrolled in an approved clinical 

11 trial, including any items or services related to the 

12 prevention, detection, and treatment of any medical 

13 complications that arise as a result of participation 

14 in the approved clinical trial. 

15 ‘‘(2) EXCLUSION.—For purposes of paragraph 

16 (1), routine patient costs does not include— 

17 ‘‘(A) the investigational item, device, or 

18 service itself; 

19 ‘‘(B) items and services that are provided 

20 solely to satisfy data collection and analysis 

21 needs and that are not used in the direct clin22 ical management of the patient; or 

23 ‘‘(C) a service that is clearly inconsistent 

24 with widely accepted and established standards 

25 of care for a particular diagnosis. 


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1 ‘‘(3) INFORMATION CONCERNING CLINICAL

2 TRIALS.— 

3 ‘‘(A) IN GENERAL.—Subject to subpara4 graph (B), the Secretary, in consultation with 

5 relevant stakeholders, shall develop a single 

6 standardized electronic form for use by the indi7 vidual or the referring health care provider to 

8 submit to the State agency administering the 

9 State plan in order to verify that the clinical 

10 trial meets the conditions established for an ap11 proved clinical trial (as defined in subsection 

12 (c)). 

13 ‘‘(B) EXCLUDED INFORMATION.—For pur14 poses of subparagraph (A) or any such request 

15 by the State agency for information regarding 

16 a clinical trial, an individual or referring health 

17 care provider shall not be required to submit— 

18 ‘‘(i) the clinical protocol document for 

19 the clinical trial; or 

20 ‘‘(ii) subject to subparagraph (C), any 

21 additional information other than such in22 formation as is required pursuant to the 

23 form described in subparagraph (A). 

24 ‘‘(C) OPTIONAL INFORMATION.—For pur25 poses of subparagraphs (A) and (B)(ii), the 


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1 form may include a requirement that the refer2 ring health care provider attest that the indi3 vidual is eligible to participate in the clinical 

4 trial pursuant to the trial protocol and that in5 dividual participation in such trial would be ap6 propriate. 

7 ‘‘(D) REVIEW OF INFORMATION.— 

8 ‘‘(i) IN GENERAL.—A State plan 

9 under this title shall establish a process for 

10 timely review by the State agency of the 

11 form and information submitted pursuant 

12 to subparagraph (A) and, not later than 

13 48 hours after receipt of such form, con14 firmation that the information provided in 

15 such form satisfies the requirements estab16 lished under such subparagraph, with such 

17 process to include establishment and oper18 ation of a 24-hour, toll-free telephone num19 ber and email address to provide for expe20 dited communication. 

21 ‘‘(ii) FAILURE TO RESPOND.—If an 

22 individual or the referring health care pro23 vider does not receive a response or re24 quest for additional information from the 

25 State agency following the 48-hour period 


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1 described in clause (i), the information 

2 provided in the form may be presumed to 

3 satisfy the requirements established under 

4 this paragraph. 

5 ‘‘(b) ENCOURAGEMENT OF PARTICIPATION IN AP6 PROVED CLINICAL TRIALS.— 

7 ‘‘(1) REASONABLY ACCESSIBLE PROVIDER.— 

8 For purposes of participation in an approved clinical 

9 trial by an individual eligible for medical assistance 

10 under this title, the State agency administering the 

11 State plan shall make reasonable efforts to ensure 

12 that the individual is provided with access to a pro13 vider who is— 

14 ‘‘(A) participating in the approved clinical 

15 trial; 

16 ‘‘(B) located not more than 25 miles from 

17 the residence of the individual (or, if no such 

18 provider is available, as close as possible to the 

19 residence of the individual); and 

20 ‘‘(C) a participating provider under the 

21 State plan or has been deemed to be a partici22 pating provider under the State plan for pur23 poses of providing medical assistance to the in24 dividual during their participation in the ap25 proved clinical trial. 


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1 ‘‘(2) INFORMATIONAL MATERIALS.—The State 

2 agency administering the plan approved under this 

3 title shall develop informational materials and pro4 grams to encourage participating providers to make 

5 appropriate referrals to physicians and other appro6 priate health care professionals who can provide in7 dividuals with access to approved clinical trials. 

8 ‘‘(c) DEFINITION OF APPROVED CLINICAL TRIAL.— 

9 The term ‘approved clinical trial’ has the same meaning 

10 as provided under section 2709(d) of the Public Health 

11 Service Act.’’. 

12 (b) CONFORMING AMENDMENT.—Section 1902(a) of 

13 the Social Security Act (42 U.S.C. 1396a(a)) is amended 

14 by inserting after paragraph (77) the following new para15 graph: 

16 ‘‘(78) provide that participation in an approved 

17 clinical trial and coverage of routine patient costs 

18 associated with such trial for an individual eligible 

19 for medical assistance under this title is conducted 

20 in accordance with the requirements under section 

21 1944;’’. 

22 (c) EFFECTIVE DATE.— 

23 (1) IN GENERAL.—Except as provided in para24 graph (2), the amendments made by this section 


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1 shall apply to calendar quarters beginning on or 

2 after October 1, 2018. 

3 (2) DELAY PERMITTED FOR STATE PLAN

4 AMENDMENT.—In the case of a State plan for med5 ical assistance under title XIX of the Social Security 

6 Act which the Secretary of Health and Human Serv7 ices determines requires State legislation (other than 

8 legislation appropriating funds) in order for the plan 

9 to meet the additional requirements imposed by the 

10 amendments made by this section, the State plan 

11 shall not be regarded as failing to comply with the 

12 requirements of such title solely on the basis of its 

13 failure to meet these additional requirements before 

14 the first day of the first calendar quarter beginning 

15 after the close of the first regular session of the 

16 State legislature that begins after the date of enact17 ment of this Act. For purposes of the previous sen18 tence, in the case of a State that has a 2-year legis19 lative session, each year of such session shall be 

20 deemed to be a separate regular session of the State 

21 legislature. 

22 Subtitle E—HIV/AIDS 

23 SEC. 741. STATEMENT OF POLICY. 

24 It is the policy of the United States to achieve an 

25 AIDS-free generation, and to— 


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1 (1) expand access to lifesaving antiretroviral 

2 therapy for people living with HIV/AIDS and imme3 diately link people to continuous and coordinated 

4 high-quality care when they learn they are infected 

5 with HIV; 

6 (2) expand targeted efforts to prevent HIV in7 fection using a combination of effective, evidence8 based approaches, including routine HIV screening, 

9 and universal access to HIV prevention tools in the 

10 communities where HIV/AIDS is most heavily con11 centrated, particularly communities of color; 

12 (3) ensure laws, policies, and regulations do not 

13 impede access to prevention, treatment, and care for 

14 people living with HIV/AIDS or at risk for acquiring 

15 HIV; 

16 (4) accelerate research for more efficacious HIV 

17 prevention and treatments tools, a cure, and a vac18 cine; and 

19 (5) respect the human rights and dignity of 

20 persons living with HIV/AIDS. 

21 SEC. 742. FINDINGS. 

22 The Congress finds the following: 

23 (1) Over one million people are estimated to be 

24 living with HIV in the United States according to 

25 the Centers for Disease Control and Prevention, 15 


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1 percent of whom are unaware of their HIV-positive 

2 status. 

3 (2) Annually there are about 37,600 new HIV 

4 infections and 20,000 deaths in people with an HIV 

5 diagnoses in 50 States and 6 dependent areas of the 

6 United States. 

7 (3) The Centers for Disease Control and Pre8 vention estimates that, in 2015, there were approxi9 mately 37,600 people newly diagnosed with HIV. 

10 The estimated number of annual new HIV infections 

11 declined 10 percent from 2010 to 2014. However, 

12 the number of new infections is increasing among 

13 certain populations, such as Latino gay and bisexual 

14 men, where annual infections increase 14 percent. 

15 New infections among Black gay or bisexual men 

16 are remaining stable. 

17 (4) HIV disproportionately affects certain popu18 lations in the United States. Though African Ameri19 cans represent approximately 12 percent of the pop20 ulation, African Americans account for almost half 

21 (45 percent) of all people living with HIV in the 

22 United States. Men who have sex with men (MSM) 

23 account for 67 percent of all new HIV infections and 

24 are the only risk group in which HIV infections con25 tinue to increase. 


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1 (5) Disparities exist among Latinos/Hispanics; 

2 they make up 18 percent of the United States popu3 lation and 24 percent of new infections (2015). 

4 (6) Though the rate of new infections among 

5 American Indians/Alaska Native (AI/AN) is propor6 tional to their population size, from 2005 to 2014, 

7 the annual number of HIV diagnoses increased 19 

8 percent among AIs/ANs overall and 63 percent 

9 among AI/AN gay and bisexual men. 

10 (7) Asian Americans account for about 2 per11 cent of new HIV infections, but in 2013, 22 percent 

12 were undiagnosed, the highest rate of undiagnosed 

13 HIV among any race/ethnicity. 

14 (8) The latest data from the CDC (2015) indi15 cate that new infections among women declined 20 

16 percent. 

17 (9) The history of HIV shows that culturally 

18 relevant and gender-responsive supportive services, 

19 including psychosocial support, treatment literacy, 

20 case management, and transportation are necessary 

21 strategies to reach and engage women and girls in 

22 medical care. 

23 (10) The limited data available on transgender 

24 individuals point to a disproportionate burden of 

25 HIV infection. 


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1 (11) Stigma and discrimination contribute to 

2 these disparities. 

3 (12) The Centers for Disease Control and Pre4 vention has determined that increasing the propor5 tion of people who know their HIV status is an es6 sential component of comprehensive HIV/AIDS 

7 treatment and prevention efforts and that early di8 agnosis is critical in order for people with HIV/ 

9 AIDS to receive life-extending therapy. Additionally, 

10 the Centers for Disease Control and Prevention rec11 ommend routine HIV screening in health care set12 tings for all patients aged 13 to 64, regardless of 

13 risk. 

14 (13) In 1998, Congress created the National 

15 Minority AIDS Initiative to provide technical assist16 ance, build capacity, and strengthen outreach efforts 

17 among local institutions and community-based orga18 nizations that serve racial and ethnic minorities liv19 ing with or vulnerable to HIV/AIDS. 

20 (14) To combat the HIV epidemic in the United 

21 States, the National HIV/AIDS Strategy (NHAS) 

22 provides a framework of increasing access to care, 

23 reducing new infections, and eliminating HIV-re24 lated health disparities. The vision of NHAS is ‘‘The 

25 United States will become a place where new HIV 


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1 infections are rare and when they do occur, every 

2 person, regardless of age, gender, race/ethnicity, 

3 gender identity, or socioeconomic circumstance, will 

4 have unfettered access to high quality, life-extending 

5 care, free from stigma and discrimination.’’. 

6 (15) At present, many States and United 

7 States territories have criminal statutes based on 

8 ‘‘exposure’’ to HIV. Most of these laws were adopted 

9 before the availability of effective antiretroviral 

10 treatment for HIV/AIDS. 

11 (16) Research shows that stable housing leads 

12 to better health outcomes for those living with HIV. 

13 Inadequate or unstable housing is not only a barrier 

14 to effective treatment, but also increases the likeli15 hood of engaging in risky behaviors leading to HIV 

16 infection. Insecure housing puts people with HIV/ 

17 AIDS at risk of premature death from exposure to 

18 other diseases, poor nutrition, and lack of medical 

19 care. 

20 (17) Due to advances in treatment, many peo21 ple living with HIV/AIDS (PLWHA) today are liv22 ing healthy lives and have the ability and desire to 

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1 ployed with tremendous economic, social, and health 

2 benefits for many people living with HIV/AIDS. 

3 (18) The common benefits associated with em4 ployment include income, autonomy, productivity, 

5 and status within society, daily structure, making a 

6 contribution to one’s community, and increased skills 

7 and self-esteem. Research also indicates that many 

8 people with disabilities, including PLWHA, report 

9 perceiving themselves as being less disabled or not 

10 disabled at all, when working. Furthermore, some 

11 studies link working with better physical and mental 

12 health outcomes for PLWHA when compared to 

13 those who are not working. Preliminary data also 

14 suggest that transitioning to employment is associ15 ated with reduced HIV-related health risk behavior 

16 for many people. 

17 (19) On July 16, 2012, the Food and Drug Ad18 ministration approved the first drug to reduce the 

19 risk of HIV infection in uninfected individuals who 

20 are at high risk of HIV infection and who may en21 gage in sexual activity with HIV-infected partners. 

22 (20) Syringe service programs (SSPs) have 

23 been associated with lowered HIV infections, lower 

24 hepatitis C infections, and increased linkage to sub25 stance use treatment. 


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1 (21) There is now conclusive scientific evidence 

2 that a person living with HIV who is on 

3 antiretroviral therapy (ART) and is durably virally 

4 suppressed (defined as having a consistent viral load 

5 of less than 200 copies/ml) does not sexually trans6 mit HIV. The conclusive evidence about the highly 

7 effective preventative benefits of ART provides an 

8 unprecedented opportunity to improve the lives of 

9 people living with HIV, improve treatment uptake 

10 and adherence, and advocate for expanded access to 

11 treatment and care. 

12 SEC. 743. ADDITIONAL FUNDING FOR AIDS DRUG ASSIST13 ANCE PROGRAM TREATMENTS. 

14 Section 2623 of the Public Health Service Act (42 

15 U.S.C. 300ff–31b) is amended by adding at the end the 

16 following: 

17 ‘‘(c) ADDITIONAL FUNDING FOR AIDS DRUG AS18 SISTANCE PROGRAM TREATMENTS.—In addition to 

19 amounts otherwise authorized to be appropriated for car20 rying out this subpart, there are authorized to be appro21 priated such sums as may be necessary to carry out sec22 tions 2612(b)(3)(B) and 2616 for each of fiscal years 

23 2019 through 2022.’’. 


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1 SEC. 744. ENHANCING THE NATIONAL HIV SURVEILLANCE 

2 SYSTEM. 

3 (a) GRANTS.—The Secretary of Health and Human 

4 Services, acting through the Director of the Centers for 

5 Disease Control and Prevention, shall make grants to 

6 States to support integration of public health surveillance 

7 systems into all electronic health records in order to allow 

8 rapid communications between the clinical setting and 

9 health departments, by means that include— 

10 (1) providing technical assistance and policy 

11 guidance to State and local health departments, clin12 ical providers, and other agencies serving individuals 

13 with HIV to improve the interoperability of data sys14 tems relevant to monitoring HIV care and sup15 portive services; 

16 (2) capturing longitudinal data pertaining to 

17 the initiation and ongoing prescription or dispensing 

18 of antiretroviral therapy for individuals diagnosed 

19 with HIV (such as through pharmacy-based report20 ing); 

21 (3) obtaining information— 

22 (A) on a voluntary basis, on sexual orienta23 tion and gender identity; and 

24 (B) on sources of coverage (or the lack 

25 thereof) for medical treatment (including cov26 erage through Medicaid, Medicare, the program 


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1 under title XXVI of the Public Health Service 

2 Act (42 U.S.C. 300ff–11 et seq.; commonly re3 ferred to as the ‘‘Ryan White HIV/AIDS Pro4 gram’’), other public funding, private insurance, 

5 and health maintenance organizations); and 

6 (4) obtaining and using current geographic 

7 markers of residence (such as current address, zip 

8 code, partial zip code, and census block). 

9 (b) PRIVACY AND SECURITY SAFEGUARDS.—In car10 rying out this section, the Secretary of Health and Human 

11 Services shall ensure that appropriate privacy and security 

12 safeguards are met to prevent unauthorized disclosure of 

13 protected health information and compliance with the 

14 HIPAA privacy and security law (as defined in section 

15 3009 of the Public Health Service Act (42 U.S.C. 300jj– 

16 19)) and other relevant laws and regulations. 

17 (c) PROHIBITION AGAINST IMPROPER USE OF

18 DATA.—No grant under this section may be used to allow 

19 or facilitate the collection or use of surveillance or clinical 

20 data or records— 

21 (1) for punitive measures of any kind, civil or 

22 criminal, against the subject of such data or records; 

23 or 


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1 (2) for imposing any requirement or restriction 

2 with respect to an individual without the individual’s 

3 written consent. 

4 (d) AUTHORIZATION OF APPROPRIATIONS.—To carry 

5 out this section, there are authorized to be appropriated 

6 such sums as may be necessary for each of fiscal years 

7 2019 through 2023. 

8 SEC. 745. EVIDENCE-BASED STRATEGIES FOR IMPROVING 

9 LINKAGE TO AND RETENTION IN APPRO10 PRIATE CARE. 

11 (a) STRATEGIES.—The Secretary of Health and 

12 Human Services, in collaboration with the Director of the 

13 Centers for Disease Control and Prevention, the Adminis14 trator of the Substance Abuse and Mental Health Services 

15 Administration, the Director of the Office of AIDS Re16 search, the Administrator of the Health Resources and 

17 Services Administration, and the Administrator of the 

18 Centers for Medicare & Medicaid Services, shall— 

19 (1) identify evidence-based strategies most ef20 fective at addressing the multifaceted issues that im21 pede disease status awareness and linkage to and re22 tention in appropriate care, taking into consideration 

23 health care systems issues, clinic and provider 

24 issues, and individual psychosocial, environmental, 

25 and other contextual factors; 


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1 (2) support the wide-scale implementation of 

2 the evidence-based strategies identified pursuant to 

3 paragraph (1), including through incorporating such 

4 strategies into health care coverage supported by the 

5 Medicaid program under title XIX of the Social Se6 curity Act (42 U.S.C. 1396 et seq.), the program 

7 under title XXVI of the Public Health Service Act 

8 (42 U.S.C. 300ff–11 et seq.; commonly referred to 

9 as the ‘‘Ryan White HIV/AIDS Program’’), and 

10 health plans purchased through an American Health 

11 Benefit Exchange established pursuant to section 

12 1311 of the Patient Protection and Affordable Care 

13 Act (42 U.S.C. 18031); and 

14 (3) not later than 12 months after the date of 

15 the enactment of this Act, submit a report to the 

16 Congress on the status of activities under para17 graphs (1) and (2). 

18 (b) AUTHORIZATION OF APPROPRIATIONS.—To carry 

19 out this section, there are authorized to be appropriated 

20 such sums as may be necessary for fiscal years 2019 

21 through 2023. 


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1 SEC. 746. IMPROVING ENTRY INTO AND RETENTION IN 

2 CARE AND ANTIRETROVIRAL ADHERENCE 

3 FOR PERSONS WITH HIV. 

4 (a) SENSE OF CONGRESS.—It is the sense of the Con5 gress that AIDS research has led to scientific advance6 ments that have— 

7 (1) saved the lives of millions of people with 

8 HIV/AIDS; 

9 (2) prevented millions of people from being in10 fected; and 

11 (3) had broad benefits that extend far beyond 

12 helping people at risk for or living with HIV. 

13 (b) IN GENERAL.—The Secretary of Health and 

14 Human Services, acting through the Director of the Na15 tional Institutes of Health, shall expand, intensify, and co16 ordinate operational and translational research and other 

17 activities of the National Institutes of Health regarding 

18 methods— 

19 (1) to increase adoption of evidence-based ad20 herence strategies within HIV care and treatment 

21 programs; 

22 (2) to increase HIV testing and case detection 

23 rates; 

24 (3) to reduce HIV-related health disparities; 


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1 (4) to ensure that research to improve adher2 ence to HIV care and treatment programs address 

3 the unique concerns of women; 

4 (5) to integrate HIV/AIDS prevention and care 

5 services with mental health and substance use pre6 vention and treatment delivery systems; 

7 (6) to increase knowledge on the implementa8 tion of preexposure prophylaxis (PrEP), including 

9 with respect to— 

10 (A) who can benefit most from PrEP; 

11 (B) how to provide PrEP safely and effi12 ciently; 

13 (C) how to integrate PrEP with other es14 sential prevention methods such as condoms; 

15 and 

16 (D) how to ensure high levels of adherence; 

17 and 

18 (7) to increase knowledge of Undetectable = 

19 Untransmittable (U=U) a person living with HIV 

20 who is on antiretroviral therapy (ART) and is dura21 bly virally suppressed (defined as having a consistent 

22 viral load of less than 200 copies/ml) cannot sexually 

23 transmit HIV. 

24 (c) AUTHORIZATION OF APPROPRIATIONS.—To carry 

25 out this section, there are authorized to be appropriated 


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1 such sums as may be necessary for fiscal years 2019 

2 through 2023. 

3 SEC. 747. SERVICES TO REDUCE HIV/AIDS IN RACIAL AND 

4 ETHNIC MINORITY COMMUNITIES. 

5 (a) IN GENERAL.—For the purpose of reducing HIV/ 

6 AIDS in racial and ethnic minority communities, the Sec7 retary, acting through the Deputy Assistant Secretary for 

8 Minority Health, may make grants to public health agen9 cies and faith-based organizations to conduct— 

10 (1) outreach activities related to HIV/AIDS 

11 prevention and testing activities; 

12 (2) HIV/AIDS prevention activities; and 

13 (3) HIV/AIDS testing activities. 

14 (b) AUTHORIZATION OF APPROPRIATIONS.—To carry 

15 out this section, there are authorized to be appropriated 

16 such sums as may be necessary for fiscal years 2019 

17 through 2023. 

18 SEC. 748. MINORITY AIDS INITIATIVE. 

19 (a) EXPANDED FUNDING.—The Secretary, in col20 laboration with the Deputy Assistant Secretary for Minor21 ity Health, the Director of the Centers for Disease Control 

22 and Prevention, the Administrator of the Health Re23 sources and Services Administration, and the Adminis24 trator of the Substance Abuse and Mental Health Services 


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1 Administration, shall provide funds and carry out activi2 ties to expand the Minority HIV/AIDS Initiative. 

3 (b) USE OF FUNDS.—The additional funds made 

4 available under this section may be used, through the Mi5 nority AIDS Initiative, to support the following activities: 

6 (1) Providing technical assistance and infra7 structure support to reduce HIV/AIDS in minority 

8 populations. 

9 (2) Increasing minority populations’ access to 

10 HIV/AIDS prevention and care services. 

11 (3) Building strong community programs and 

12 partnerships to address HIV prevention and the 

13 health care needs of specific racial and ethnic minor14 ity populations. 

15 (c) PRIORITY INTERVENTIONS.—Within the racial 

16 and ethnic minority populations referred to in subsection 

17 (b), priority in conducting intervention services shall be 

18 given to— 

19 (1) men who have sex with men; 

20 (2) youth; 

21 (3) persons who engage in intravenous drug 

22 abuse; 

23 (4) women; 

24 (5) homeless individuals; and 


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1 (6) individuals incarcerated or in the penal sys2 tem. 

3 (d) AUTHORIZATION OF APPROPRIATIONS.—For car4 rying out this section, there are authorized to be appro5 priated $610,000,000 for fiscal year 2019 and such sums 

6 as may be necessary for each of fiscal years 2020 through 

7 2023. 

8 SEC. 749. HEALTH CARE PROFESSIONALS TREATING INDI9 VIDUALS WITH HIV/AIDS. 

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

11 Human Services, acting through the Administrator of the 

12 Health Resources and Services Administration, shall ex13 pand, intensify, and coordinate workforce initiatives of the 

14 Health Resources and Services Administration to increase 

15 the capacity of the health workforce focusing primarily on 

16 HIV/AIDS to meet the demand for culturally competent 

17 care, and may award grants for any of the following: 

18 (1) Development of curricula for training pri19 mary care providers in HIV/AIDS prevention and 

20 care, including routine HIV testing. 

21 (2) Support to expand access to culturally and 

22 linguistically accessible benefits counselors, trained 

23 peer navigators, and mental and behavioral health 

24 professionals with expertise in HIV/AIDS. 


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1 (3) Training health care professionals to pro2 vide care to individuals with HIV/AIDS. 

3 (4) Development by grant recipients under title 

4 XXVI of the Public Health Service Act (42 U.S.C. 

5 300ff–11 et seq.; commonly referred to as the ‘‘Ryan 

6 White HIV/AIDS Program’’) and other persons, of 

7 policies for providing culturally relevant and sen8 sitive treatment to individuals with HIV/AIDS, with 

9 particular emphasis on treatment to racial and eth10 nic minorities, men who have sex with men, and 

11 women, young people, and children with HIV/AIDS. 

12 (5) Development and implementation of pro13 grams to increase the use of telehealth to respond to 

14 HIV/AIDS-specific health care needs in rural and 

15 minority communities, with particular emphasis 

16 given to medically underserved communities and in17 sular areas. 

18 (6) Evaluating interdisciplinary medical pro19 vider care team models that promote high-quality 

20 care, with particular emphasis on care to racial and 

21 ethnic minorities. 

22 (7) Training health care professionals to make 

23 them aware of the high rates of chronic hepatitis B 

24 and chronic hepatitis C in adult racial and ethnic 

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1 tection, and medical management of hepatitis B and 

2 hepatitis C and of liver cancer screening. 

3 (8) Development of curricula for training pri4 mary care providers that HIV/AIDS and tuber5 culosis are significant mutual comorbidities, and 

6 that a patient who tests positive for one disease 

7 should be offered and encouraged to receive testing 

8 for the other. 

9 (b) AUTHORIZATION OF APPROPRIATIONS.—To carry 

10 out this section, there are authorized to be appropriated 

11 such sums as may be necessary for fiscal years 2019 

12 through 2023. 

13 SEC. 750. HIV/AIDS PROVIDER LOAN REPAYMENT PRO14 GRAM. 

15 (a) IN GENERAL.—The Secretary may enter into an 

16 agreement with any physician, nurse practitioner, or phy17 sician assistant under which— 

18 (1) the physician, nurse practitioner, or physi19 cian assistant agrees to serve as a medical provider 

20 for a period of not less than 2 years— 

21 (A) at a Ryan White-funded or title X22 funded facility with a critical shortage of doc23 tors (as determined by the Secretary); or 

24 (B) in an area with a high incidence of 

25 HIV/AIDS; and 


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1 (2) the Secretary agrees to make payments in 

2 accordance with subsection (b) on the professional 

3 education loans of the physician, nurse practitioner, 

4 or physician assistant. 

5 (b) MANNER OF PAYMENTS.—The payments de6 scribed in subsection (a) shall be made by the Secretary 

7 as follows: 

8 (1) Upon completion by the physician, nurse 

9 practitioner, or physician assistant for whom the 

10 payments are to be made of the first year of the 

11 service specified in the agreement entered into with 

12 the Secretary under subsection (a), the Secretary 

13 shall pay 30 percent of the principal of and the in14 terest on the individual’s professional education 

15 loans. 

16 (2) Upon completion by the physician, nurse 

17 practitioner, or physician assistant of the second 

18 year of such service, the Secretary shall pay another 

19 30 percent of the principal of and the interest on 

20 such loans. 

21 (3) Upon completion by that individual of a 

22 third year of such service, the Secretary shall pay 

23 another 25 percent of the principal of and the inter24 est on such loans. 


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1 (c) APPLICABILITY OF CERTAIN PROVISIONS.—The 

2 provisions of subpart III of part D of title III of the Public 

3 Health Service Act (42 U.S.C. 254l et seq.) shall, except 

4 as inconsistent with this section, apply to the program car5 ried out under this section in the same manner and to 

6 the same extent as such provisions apply to the National 

7 Health Service Corps Loan Repayment Program. 

8 (d) REPORTS.—Not later than 18 months after the 

9 date of the enactment of this Act, and annually thereafter, 

10 the Secretary shall prepare and submit to the Congress 

11 a report describing the program carried out under this sec12 tion, including statements regarding the following: 

13 (1) The number of physicians, nurse practi14 tioners, and physician assistants enrolled in the pro15 gram. 

16 (2) The number and amount of loan repay17 ments. 

18 (3) The placement location of loan repayment 

19 recipients at facilities described in subsection (a)(1). 

20 (4) The default rate and actions required. 

21 (5) The amount of outstanding default funds. 

22 (6) To the extent that it can be determined, the 

23 reason for the default. 

24 (7) The demographics of individuals partici25 pating in the program. 


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1 (8) An evaluation of the overall costs and bene2 fits of the program. 

3 (e) DEFINITIONS.—In this section: 

4 (1) HIV/AIDS.—The term ‘‘HIV/AIDS’’ means 

5 human immunodeficiency virus and acquired im6 mune deficiency syndrome. 

7 (2) NURSE PRACTITIONER.—The term ‘‘nurse 

8 practitioner’’ means a registered nurse who has com9 pleted an accredited graduate degree program in ad10 vanced nurse practice and has successfully passed a 

11 national certification exam. 

12 (3) PHYSICIAN.—The term ‘‘physician’’ means 

13 a graduate of a school of medicine who has com14 pleted postgraduate training in general or pediatric 

15 medicine. 

16 (4) PHYSICIAN ASSISTANT.—The term ‘‘physi17 cian assistant’’ means a medical provider who com18 pleted an accredited physician assistant training pro19 gram and successfully passed the Physician Assist20 ant National Certifying Examination. 

21 (5) PROFESSIONAL EDUCATION LOAN.—The 

22 term ‘‘professional education loan’’— 

23 (A) means a loan that is incurred for the 

24 cost of attendance (including tuition, other rea25 sonable educational expenses, and reasonable 


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1 living costs) at a school of medicine, nursing, or 

2 physician assistant training program; and 

3 (B) includes only the portion of the loan 

4 that is outstanding on the date the physician, 

5 nurse practitioner, or physician assistant in6 volved begins the service specified in the agree7 ment under subsection (a). 

8 (6) RYAN WHITE-FUNDED.—The term ‘‘Ryan 

9 White-funded’’ means, with respect to a facility, re10 ceiving funds under title XXVI of the Public Health 

11 Service Act (42 U.S.C. 300ff–11 et seq.). 

12 (7) SECRETARY.—The term ‘‘Secretary’’ means 

13 the Secretary of Health and Human Services. 

14 (8) SCHOOL OF MEDICINE.—The term ‘‘school 

15 of medicine’’ has the meaning given to that term in 

16 section 799B of the Public Health Service Act (42 

17 U.S.C. 295p). 

18 (9) TITLE X-FUNDED.—The term ‘‘title X-fund19 ed’’ means, with respect to a facility, receiving funds 

20 under title X of the Public Health Service Act (42 

21 U.S.C. 300 et seq.). 

22 (f) AUTHORIZATION OF APPROPRIATIONS.—To carry 

23 out this section, there are authorized to be appropriated 

24 such sums as may be necessary for fiscal years 2019 

25 through 2023. 


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1 SEC. 751. DENTAL EDUCATION LOAN REPAYMENT PRO2 GRAM. 

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

4 Human Services may enter into an agreement with any 

5 dentist under which— 

6 (1) the dentist agrees to serve as a dentist for 

7 a period of not less than 2 years at a facility with 

8 a critical shortage of dentists (as determined by the 

9 Secretary) in an area with a high incidence of HIV/ 

10 AIDS; and 

11 (2) the Secretary agrees to make payments in 

12 accordance with subsection (b) on the dental edu13 cation loans of the dentist. 

14 (b) MANNER OF PAYMENTS.—The payments de15 scribed in subsection (a) shall be made by the Secretary 

16 as follows: 

17 (1) Upon completion by the dentist for whom 

18 the payments are to be made of the first year of the 

19 service specified in the agreement entered into with 

20 the Secretary under subsection (a), the Secretary 

21 shall pay 30 percent of the principal of and the in22 terest on the dental education loans of the dentist. 

23 (2) Upon completion by the dentist of the sec24 ond year of such service, the Secretary shall pay an25 other 30 percent of the principal of and the interest 

26 on such loans. 


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1 (3) Upon completion by that individual of a 

2 third year of such service, the Secretary shall pay 

3 another 25 percent of the principal of and the inter4 est on such loans. 

5 (c) APPLICABILITY OF CERTAIN PROVISIONS.—The 

6 provisions of subpart III of part D of title III of the Public 

7 Health Service Act (42 U.S.C. 254l et seq.) shall, except 

8 as inconsistent with this section, apply to the program car9 ried out under this section in the same manner and to 

10 the same extent as such provisions apply to the National 

11 Health Service Corps Loan Repayment Program. 

12 (d) REPORTS.—Not later than 18 months after the 

13 date of the enactment of this Act, and annually thereafter, 

14 the Secretary shall prepare and submit to the Congress 

15 a report describing the program carried out under this sec16 tion, including statements regarding the following: 

17 (1) The number of dentists enrolled in the pro18 gram. 

19 (2) The number and amount of loan repay20 ments. 

21 (3) The placement location of loan repayment 

22 recipients at facilities described in subsection (a)(1). 

23 (4) The default rate and actions required. 

24 (5) The amount of outstanding default funds. 


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1 (6) To the extent that it can be determined, the 

2 reason for the default. 

3 (7) The demographics of individuals partici4 pating in the program. 

5 (8) An evaluation of the overall costs and bene6 fits of the program. 

7 (e) DEFINITIONS.—In this section: 

8 (1) DENTAL EDUCATION LOAN.—The term 

9 ‘‘dental education loan’’— 

10 (A) means a loan that is incurred for the 

11 cost of attendance (including tuition, other rea12 sonable educational expenses, and reasonable 

13 living costs) at a school of dentistry; and 

14 (B) includes only the portion of the loan 

15 that is outstanding on the date the dentist in16 volved begins the service specified in the agree17 ment under subsection (a). 

18 (2) DENTIST.—The term ‘‘dentist’’ means a 

19 graduate of a school of dentistry who has completed 

20 postgraduate training in general or pediatric den21 tistry. 

22 (3) HIV/AIDS.—The term ‘‘HIV/AIDS’’ means 

23 human immunodeficiency virus and acquired im24 mune deficiency syndrome. 


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1 (4) SCHOOL OF DENTISTRY.—The term ‘‘school 

2 of dentistry’’ has the meaning given to that term in 

3 section 799B of the Public Health Service Act (42 

4 U.S.C. 295p). 

5 (5) SECRETARY.—The term ‘‘Secretary’’ means 

6 the Secretary of Health and Human Services. 

7 (f) AUTHORIZATION OF APPROPRIATIONS.—To carry 

8 out this section, there are authorized to be appropriated 

9 such sums as may be necessary for each of fiscal years 

10 2019 through 2023. 

11 SEC. 752. REDUCING NEW HIV INFECTIONS AMONG INJECT12 ING DRUG USERS. 

13 (a) SENSE OF CONGRESS.—It is the sense of the Con14 gress that providing sterile syringes and sterilized equip15 ment to injecting drug users substantially reduces risk of 

16 HIV infection, increases the probability that they will ini17 tiate drug treatment, and does not increase drug use. 

18 (b) IN GENERAL.—The Secretary of Health and 

19 Human Services may provide grants and technical assist20 ance for the purpose of reducing the rate of HIV infections 

21 among injecting drug users through a comprehensive 

22 package of services for such users, including the provision 

23 of sterile syringes, education and outreach, access to infec24 tious disease testing, overdose prevention, and treatment 

25 for drug dependence. 


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1 (c) AUTHORIZATION OF APPROPRIATIONS.—To carry 

2 out this section, there are authorized to be appropriated 

3 such sums as may be necessary for fiscal years 2019 

4 through 2023. 

5 SEC. 753. REPORT ON IMPACT OF HIV/AIDS IN VULNERABLE 

6 POPULATIONS. 

7 (a) IN GENERAL.—The Secretary shall submit to the 

8 Congress and the President an annual report on the im9 pact of HIV/AIDS for racial and ethnic minority commu10 nities, women, and youth aged 24 and younger. 

11 (b) CONTENTS.—The report under subsection (a) 

12 shall include information on the— 

13 (1) progress that has been made in reducing 

14 the impact of HIV/AIDS in such communities; 

15 (2) opportunities that exist to make additional 

16 progress in reducing the impact of HIV/AIDS in 

17 such communities; 

18 (3) challenges that may impede such additional 

19 progress; and 

20 (4) Federal funding necessary to achieve sub21 stantial reductions in HIV/AIDS in racial and ethnic 

22 minority communities. 

23 SEC. 754. NATIONAL HIV/AIDS OBSERVANCE DAYS. 

24 (a) NATIONAL OBSERVANCE DAYS.—It is the sense 

25 of the Congress that national observance days highlighting 


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1 the impact of HIV/AIDS on communities of color include 

2 the following: 

3 (1) National Black HIV/AIDS Awareness Day. 

4 (2) National Latino AIDS Awareness Day. 

5 (3) National Asian and Pacific Islander HIV/ 

6 AIDS Awareness Day. 

7 (4) National Native American HIV/AIDS 

8 Awareness Day. 

9 (5) National Youth HIV/AIDS Awareness Day. 

10 (b) CALL TO ACTION.—It is the sense of the Con11 gress that the President should call on members of com12 munities of color— 

13 (1) to become involved at the local community 

14 level in HIV/AIDS testing, policy, and advocacy; 

15 (2) to become aware, engaged, and empowered 

16 on the HIV/AIDS epidemic within their commu17 nities; and 

18 (3) to urge members of their communities to re19 duce risk factors, practice safe sex and other preven20 tive measures, be tested for HIV/AIDS, and seek 

21 care when appropriate. 


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1 SEC. 755. REVIEW OF ALL FEDERAL AND STATE LAWS, 

2 POLICIES, AND REGULATIONS REGARDING 

3 THE CRIMINAL PROSECUTION OF INDIVID4 UALS FOR HIV-RELATED OFFENSES. 

5 (a) DEFINITIONS.— 

6 (1) HIV AND HIV/AIDS.—The terms ‘‘HIV’’ and 

7 ‘‘HIV/AIDS’’ have the meanings given to such terms 

8 in section 2689 of the Public Health Service Act (42 

9 U.S.C. 300ff–88). 

10 (2) STATE.—The term ‘‘State’’ includes the 

11 District of Columbia, American Samoa, the Com12 monwealth of the Northern Mariana Islands, Guam, 

13 Puerto Rico, and the United States Virgin Islands. 

14 (b) SENSE OF CONGRESS REGARDING LAWS OR REG15 ULATIONS DIRECTED AT PEOPLE LIVING WITH HIV/ 

16 AIDS.—It is the sense of the Congress that Federal and 

17 State laws, policies, and regulations regarding people liv18 ing with HIV/AIDS— 

19 (1) should not place unique or additional bur20 dens on such individuals solely as a result of their 

21 HIV status; and 

22 (2) should instead demonstrate a public health23 oriented, evidence-based, medically accurate, and 

24 contemporary understanding of— 

25 (A) the multiple factors that lead to HIV 

26 transmission; 


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1 (B) the relative risk of HIV transmission 

2 routes; 

3 (C) the current health implications of liv4 ing with HIV; 

5 (D) the associated benefits of treatment 

6 and support services for people living with HIV; 

7 and 

8 (E) the impact of punitive HIV-specific 

9 laws and policies on public health, on people liv10 ing with or affected by HIV, and on their fami11 lies and communities. 

12 (c) REVIEW OF ALL FEDERAL AND STATE LAWS, 

13 POLICIES, AND REGULATIONS REGARDING THE CRIMINAL

14 PROSECUTION OF INDIVIDUALS FOR HIV-RELATED OF15 FENSES.— 

16 (1) REVIEW OF FEDERAL AND STATE LAWS.— 

17 (A) IN GENERAL.—No later than 90 days 

18 after the date of the enactment of this Act, the 

19 Attorney General, the Secretary of Health and 

20 Human Services, and the Secretary of Defense 

21 acting jointly (in this paragraph and paragraph 

22 (2) referred to as the ‘‘designated officials’’) 

23 shall initiate a national review of Federal and 

24 State laws, policies, regulations, and judicial 

25 precedents and decisions regarding criminal and 


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1 related civil commitment cases involving people 

2 living with HIV/AIDS, including in regards to 

3 the Uniform Code of Military Justice. 

4 (B) CONSULTATION.—In carrying out the 

5 review under subparagraph (A), the designated 

6 officials shall ensure diverse participation and 

7 consultation from each State, including with— 

8 (i) State attorneys general (or their 

9 representatives); 

10 (ii) State public health officials (or 

11 their representatives); 

12 (iii) State judicial and court system 

13 officers, including judges, district attor14 neys, prosecutors, defense attorneys, law 

15 enforcement, and correctional officers; 

16 (iv) members of the United States 

17 Armed Forces, including members of other 

18 Federal services subject to the Uniform 

19 Code of Military Justice; 

20 (v) people living with HIV/AIDS, par21 ticularly those who have been subject to 

22 HIV-related prosecution or who are from 

23 communities whose members have been 

24 disproportionately subject to HIV-specific 

25 arrests and prosecutions; 


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1 (vi) legal advocacy and HIV/AIDS 

2 service organizations that work with people 

3 living with HIV/AIDS; 

4 (vii) nongovernmental health organi5 zations that work on behalf of people living 

6 with HIV/AIDS; and 

7 (viii) trade organizations or associa8 tions representing persons or entities de9 scribed in clauses (i) through (vii). 

10 (C) RELATION TO OTHER REVIEWS.—In 

11 carrying out the review under subparagraph 

12 (A), the designated officials may utilize other 

13 existing reviews of criminal and related civil 

14 commitment cases involving people living with 

15 HIV/AIDS, including any such review con16 ducted by any Federal or State agency or any 

17 public health, legal advocacy, or trade organiza18 tion or association if the designated officials de19 termine that such reviews were conducted in ac20 cordance with the principles set forth in sub21 section (b). 

22 (2) REPORT.—No later than 180 days after ini23 tiating the review required by paragraph (1), the At24 torney General shall transmit to the Congress and 


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1 make publicly available a report containing the re2 sults of the review, which includes the following: 

3 (A) For each State and for the Uniform 

4 Code of Military Justice, a summary of the rel5 evant laws, policies, regulations, and judicial 

6 precedents and decisions regarding criminal 

7 cases involving people living with HIV/AIDS, 

8 including, if applicable, the following: 

9 (i) A determination of whether such 

10 laws, policies, regulations, and judicial 

11 precedents and decisions place any unique 

12 or additional burdens upon people living 

13 with HIV/AIDS. 

14 (ii) A determination of whether such 

15 laws, policies, regulations, and judicial 

16 precedents and decisions demonstrate a 

17 public health-oriented, evidence-based, 

18 medically accurate, and contemporary un19 derstanding of— 

20 (I) the multiple factors that lead 

21 to HIV transmission; 

22 (II) the relative risk of HIV 

23 transmission routes; 

24 (III) the current health implica25 tions of living with HIV; 


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1 (IV) the associated benefits of 

2 treatment and support services for 

3 people living with HIV; and 

4 (V) the impact of punitive HIV5 specific laws and policies on public 

6 health, on people living with or af7 fected by HIV, and on their families 

8 and communities. 

9 (iii) An analysis of the public health 

10 and legal implications of such laws, poli11 cies, regulations, and judicial precedents, 

12 including an analysis of the consequences 

13 of having a similar penal scheme applied to 

14 comparable situations involving other com15 municable diseases. 

16 (iv) An analysis of the proportionality 

17 of punishments imposed under HIV-spe18 cific laws, policies, regulations, and judicial 

19 precedents, taking into consideration pen20 alties attached to violation of State laws 

21 against similar degrees of endangerment or 

22 harm, such as driving while intoxicated 

23 (DWI) or transmission of other commu24 nicable diseases, or more serious harms, 

25 such as vehicular manslaughter offenses. 


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1 (B) An analysis of common elements 

2 shared among State laws, policies, regulations, 

3 and judicial precedents. 

4 (C) A set of best practice recommendations 

5 directed to State governments, including State 

6 attorneys general, public health officials, and 

7 judicial officers, in order to ensure that laws, 

8 policies, regulations, and judicial precedents re9 garding people living with HIV/AIDS are in ac10 cordance with the principles set forth in sub11 section (b). 

12 (D) Recommendations for adjustments to 

13 the Uniform Code of Military Justice, as may 

14 be necessary, in order to ensure that laws, poli15 cies, regulations, and judicial precedents re16 garding people living with HIV/AIDS are in ac17 cordance with the principles set forth in sub18 section (b). 

19 (3) GUIDANCE.—Within 90 days of the release 

20 of the report required by paragraph (2), the Attor21 ney General and the Secretary of Health and 

22 Human Services, acting jointly, shall develop and 

23 publicly release updated guidance for States based 

24 on the set of best practice recommendations required 

25 by paragraph (2)(C) in order to assist States dealing 


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1 with criminal and related civil commitment cases re2 garding people living with HIV/AIDS. 

3 (4) MONITORING AND EVALUATION SYSTEM.— 

4 Within 60 days of the release of the guidance re5 quired by paragraph (3), the Attorney General and 

6 the Secretary of Health and Human Services, acting 

7 jointly, shall establish an integrated monitoring and 

8 evaluation system which includes, where appropriate, 

9 objective and quantifiable performance goals and in10 dicators to measure progress toward statewide im11 plementation in each State of the best practice rec12 ommendations required in paragraph (2)(C), includ13 ing to monitor, track, and evaluate the effectiveness 

14 of assistance provided pursuant to subsection (d). 

15 (5) ADJUSTMENTS TO FEDERAL LAWS, POLI16 CIES, OR REGULATIONS.—Within 90 days of the re17 lease of the report required by paragraph (2), the 

18 Attorney General, the Secretary of Health and 

19 Human Services, and the Secretary of Defense, act20 ing jointly, shall develop and transmit to the Presi21 dent and the Congress, and make publicly available, 

22 such proposals as may be necessary to implement 

23 adjustments to Federal laws, policies, or regulations, 

24 including to the Uniform Code of Military Justice, 

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1 graph (2)(D), either through Executive order or 

2 through changes to statutory law. 

3 (6) AUTHORIZATION OF APPROPRIATIONS.— 

4 (A) IN GENERAL.—There are authorized to 

5 be appropriated such sums as may be necessary 

6 for the purpose of carrying out this subsection. 

7 Amounts authorized to be appropriated by the 

8 preceding sentence are in addition to amounts 

9 otherwise authorized to be appropriated for 

10 such purpose. 

11 (B) AVAILABILITY OF FUNDS.—Amounts 

12 appropriated pursuant to the authorization of 

13 appropriations in subparagraph (A) are author14 ized to remain available until expended. 

15 (d) AUTHORIZATION TO PROVIDE GRANTS.— 

16 (1) GRANTS BY ATTORNEY GENERAL.— 

17 (A) IN GENERAL.—The Attorney General 

18 may provide assistance to eligible State and 

19 local entities and eligible nongovernmental orga20 nizations for the purpose of incorporating the 

21 best practice recommendations developed under 

22 subsection (c)(2)(C) within relevant State laws, 

23 policies, regulations, and judicial decisions re24 garding people living with HIV/AIDS. 


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1 (B) AUTHORIZED ACTIVITIES.—The assist2 ance authorized by subparagraph (A) may in3 clude— 

4 (i) direct technical assistance to eligi5 ble State and local entities in order to de6 velop, disseminate, or implement State 

7 laws, policies, regulations, or judicial deci8 sions that conform with the best practice 

9 recommendations developed under sub10 section (c)(2)(C); 

11 (ii) direct technical assistance to eligi12 ble nongovernmental organizations in order 

13 to provide education and training, includ14 ing through classes, conferences, meetings, 

15 and other educational activities, to eligible 

16 State and local entities; and 

17 (iii) subcontracting authority to allow 

18 eligible State and local entities and eligible 

19 nongovernmental organizations to seek 

20 technical assistance from legal and public 

21 health experts with a demonstrated under22 standing of the principles underlying the 

23 best practice recommendations developed 

24 under subsection (c)(2)(C). 


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1 (2) GRANTS BY SECRETARY OF HEALTH AND

2 HUMAN SERVICES.— 

3 (A) IN GENERAL.—The Secretary of 

4 Health and Human Services, acting through the 

5 Director of the Centers for Disease Control and 

6 Prevention, may provide assistance to State and 

7 local public health departments and eligible 

8 nongovernmental organizations for the purpose 

9 of supporting eligible State and local entities to 

10 incorporate the best practice recommendations 

11 developed under subsection (c)(2)(C) within rel12 evant State laws, policies, regulations, and judi13 cial decisions regarding people living with HIV/ 

14 AIDS. 

15 (B) AUTHORIZED ACTIVITIES.—The assist16 ance authorized by subparagraph (A) may in17 clude— 

18 (i) direct technical assistance to State 

19 and local public health departments in 

20 order to support the development, dissemi21 nation, or implementation of State laws, 

22 policies, regulations, or judicial decisions 

23 that conform with the set of best practice 

24 recommendations developed under sub25 section (c)(2)(C); 


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1 (ii) direct technical assistance to eligi2 ble nongovernmental organizations in order 

3 to provide education and training, includ4 ing through classes, conferences, meetings, 

5 and other educational activities, to State 

6 and local public health departments; and 

7 (iii) subcontracting authority to allow 

8 State and local public health departments 

9 and eligible nongovernmental organizations 

10 to seek technical assistance from legal and 

11 public health experts with a demonstrated 

12 understanding of the principles underlying 

13 the best practice recommendations devel14 oped under subsection (c)(2)(C). 

15 (3) LIMITATION.—As a condition of receiving 

16 assistance through this subsection, eligible State and 

17 local entities, State and local public health depart18 ments, and eligible nongovernmental organizations 

19 shall agree— 

20 (A) not to place any unique or additional 

21 burdens on people living with HIV/AIDS solely 

22 as a result of their HIV status; and 

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1 ing with HIV/AIDS, such actions shall dem2 onstrate a public health-oriented, evidence3 based, medically accurate, and contemporary 

4 understanding of— 

5 (i) the multiple factors that lead to 

6 HIV transmission; 

7 (ii) the relative risk of HIV trans8 mission routes; 

9 (iii) the current health implications of 

10 living with HIV; 

11 (iv) the associated benefits of treat12 ment and support services for people living 

13 with HIV; and 

14 (v) the impact of punitive HIV-spe15 cific laws and policies on public health, on 

16 people living with or affected by HIV, and 

17 on their families and communities. 

18 (4) REPORT.—No later than 1 year after the 

19 date of the enactment of this Act, and annually 

20 thereafter, the Attorney General and the Secretary 

21 of Health and Human Services, acting jointly, shall 

22 transmit to Congress and make publicly available a 

23 report describing, for each State, the impact and ef24 fectiveness of the assistance provided through this 

25 Act. Each such report shall include— 


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1 (A) a detailed description of the progress 

2 each State has made, if any, in implementing 

3 the best practice recommendations developed 

4 under subsection (c)(2)(C) as a result of the as5 sistance provided under this subsection, and 

6 based on the performance goals and indicators 

7 established as part of the monitoring and eval8 uation system in subsection (c)(4); 

9 (B) a brief summary of any outreach ef10 forts undertaken during the prior year by the 

11 Attorney General and the Secretary of Health 

12 and Human Services to encourage States to 

13 seek assistance under this subsection in order 

14 to implement the best practice recommenda15 tions developed under subsection (c)(2)(C); 

16 (C) a summary of how assistance provided 

17 through this subsection is being utilized by eli18 gible State and local entities, State and local 

19 public health departments, and eligible non20 governmental organizations and, if applicable, 

21 any contractors, including with respect to non22 governmental organizations, the type of tech23 nical assistance provided, and an evaluation of 

24 the impact of such assistance on eligible State 

25 and local entities; and 


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1 (D) a summary and description of eligible 

2 State and local entities, State and local public 

3 health departments, and eligible nongovern4 mental organizations receiving assistance 

5 through this subsection, including if applicable, 

6 a summary and description of any contractors 

7 selected to assist in implementing such assist8 ance. 

9 (5) DEFINITIONS.—For the purposes of this 

10 subsection: 

11 (A) ELIGIBLE STATE AND LOCAL ENTI12 TIES.—The term ‘‘eligible State and local enti13 ties’’ means the relevant individuals, offices, or 

14 organizations that directly participate in the de15 velopment, dissemination, or implementation of 

16 State laws, policies, regulations, or judicial deci17 sions, including— 

18 (i) State governments, including State 

19 attorneys general, State departments of 

20 justice, and State National Guards, or 

21 their equivalents; 

22 (ii) State judicial and court systems, 

23 including trial courts, appellate courts, 

24 State supreme courts and courts of appeal, 


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1 and State correctional facilities, or their 

2 equivalents; and 

3 (iii) local governments, including city 

4 and county governments, district attorneys, 

5 and local law enforcement departments, or 

6 their equivalents. 

7 (B) STATE AND LOCAL PUBLIC HEALTH

8 DEPARTMENTS.—The term ‘‘State and local 

9 public health departments’’ means the fol10 lowing: 

11 (i) State public health departments, or 

12 their equivalents, including the chief officer 

13 of such departments and infectious disease 

14 and communicable disease specialists with15 in such departments. 

16 (ii) Local public health departments, 

17 or their equivalents, including city and 

18 county public health departments, the chief 

19 officer of such departments, and infectious 

20 disease and communicable disease special21 ists within such departments. 

22 (iii) Public health departments or offi23 cials, or their equivalents, within State or 

24 local correctional facilities. 


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1 (iv) Public health departments or offi2 cials, or their equivalents, within State Na3 tional Guards. 

4 (v) Any other recognized State or 

5 local public health organization or entity 

6 charged with carrying out official State or 

7 local public health duties. 

8 (C) ELIGIBLE NONGOVERNMENTAL ORGA9 NIZATIONS.—The term ‘‘eligible nongovern10 mental organizations’’ means the following: 

11 (i) Nongovernmental organizations, 

12 including trade organizations or associa13 tions that represent— 

14 (I) State attorneys general, or 

15 their equivalents; 

16 (II) State public health officials, 

17 or their equivalents; 

18 (III) State judicial and court offi19 cers, including judges, district attor20 neys, prosecutors, defense attorneys, 

21 law enforcement, and correctional offi22 cers; 

23 (IV) State National Guards; 

24 (V) people living with HIV/AIDS; 


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1 (VI) legal advocacy and HIV/ 

2 AIDS service organizations that work 

3 with people living with HIV/AIDS; 

4 and 

5 (VII) nongovernmental health or6 ganizations that work on behalf of 

7 people living with HIV/AIDS. 

8 (ii) Nongovernmental organizations, 

9 including trade organizations or associa10 tions that demonstrate a public-health ori11 ented, evidence-based, medically accurate, 

12 and contemporary understanding of— 

13 (I) the multiple factors that lead 

14 to HIV transmission; 

15 (II) the relative risk of HIV 

16 transmission routes; 

17 (III) the current health implica18 tions of living with HIV; 

19 (IV) the associated benefits of 

20 treatment and support services for 

21 people living with HIV; and 

22 (V) the impact of punitive HIV23 specific laws and policies on public 

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1 fected by HIV, and on their families 

2 and communities. 

3 (6) AUTHORIZATION OF APPROPRIATIONS.— 

4 (A) IN GENERAL.—In addition to amounts 

5 otherwise made available, there are authorized 

6 to be appropriated to the Attorney General and 

7 the Secretary of Health and Human Services 

8 such sums as may be necessary to carry out 

9 this subsection for each of the fiscal years 2019 

10 through 2023. 

11 (B) AVAILABILITY OF FUNDS.—Amounts 

12 appropriated pursuant to the authorizations of 

13 appropriations in subparagraph (A) are author14 ized to remain available until expended. 

15 SEC. 756. EXPANDING SUPPORT FOR CONDOMS IN PRIS16 ONS. 

17 (a) AUTHORITY TO ALLOW COMMUNITY ORGANIZA18 TIONS TO PROVIDE STI COUNSELING, STI PREVENTION

19 EDUCATION, AND SEXUAL BARRIER PROTECTION DE20 VICES IN FEDERAL CORRECTIONAL FACILITIES.— 

21 (1) DIRECTIVE TO ATTORNEY GENERAL.—Not 

22 later than 30 days after the date of enactment of 

23 this Act, the Attorney General shall direct the Bu24 reau of Prisons to allow community organizations to 

25 distribute sexual barrier protection devices and to 


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1 engage in STI counseling and STI prevention edu2 cation in Federal correctional facilities. These activi3 ties shall be subject to all relevant Federal laws and 

4 regulations which govern visitation in correctional 

5 facilities. 

6 (2) INFORMATION REQUIREMENT.—Any com7 munity organization permitted to distribute sexual 

8 barrier protection devices under paragraph (1) shall 

9 ensure that the persons to whom the devices are dis10 tributed are informed about the proper use and dis11 posal of sexual barrier protection devices in accord12 ance with established public health practices. Any 

13 community organization conducting STI counseling 

14 or STI prevention education under paragraph (1) 

15 shall offer comprehensive sexuality education. 

16 (3) POSSESSION OF DEVICE PROTECTED.—No 

17 Federal correctional facility may, because of the pos18 session or use of a sexual barrier protection device— 

19 (A) take adverse action against an incar20 cerated person; or 

21 (B) consider possession or use as evidence 

22 of prohibited activity for the purpose of any 

23 Federal correctional facility administrative pro24 ceeding. 


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1 (4) IMPLEMENTATION.—The Attorney General 

2 and Bureau of Prisons shall implement this section 

3 according to established public health practices in a 

4 manner that protects the health, safety, and privacy 

5 of incarcerated persons and of correctional facility 

6 staff. 

7 (b) SENSE OF CONGRESS REGARDING DISTRIBUTION

8 OF SEXUAL BARRIER PROTECTION DEVICES IN STATE

9 PRISON SYSTEMS.—It is the sense of the Congress that 

10 States should allow for the legal distribution of sexual bar11 rier protection devices in State correctional facilities to re12 duce the prevalence and spread of STIs in those facilities. 

13 (c) SURVEY OF AND REPORT ON CORRECTIONAL FA14 CILITY PROGRAMS AIMED AT REDUCING THE SPREAD OF

15 STIS.— 

16 (1) SURVEY.—The Attorney General, after con17 sulting with the Secretary of Health and Human 

18 Services, State officials, and community organiza19 tions, shall, to the maximum extent practicable, con20 duct a survey of all Federal and State correctional 

21 facilities, not later than 180 days after the date of 

22 enactment of this Act and annually thereafter for 5 

23 years, to determine the following: 

24 (A) COUNSELING, TREATMENT, AND SUP25 PORTIVE SERVICES.—Whether the correctional 


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1 facility requires incarcerated persons to partici2 pate in counseling, treatment, and supportive 

3 services related to STIs, or whether it offers 

4 such programs to incarcerated persons. 

5 (B) ACCESS TO SEXUAL BARRIER PROTEC6 TION DEVICES.—Whether incarcerated persons 

7 can— 

8 (i) possess sexual barrier protection 

9 devices; 

10 (ii) purchase sexual barrier protection 

11 devices; 

12 (iii) purchase sexual barrier protection 

13 devices at a reduced cost; and 

14 (iv) obtain sexual barrier protection 

15 devices without cost. 

16 (C) INCIDENCE OF SEXUAL VIOLENCE.— 

17 The incidence of sexual violence and assault 

18 committed by incarcerated persons and by cor19 rectional facility staff. 

20 (D) PREVENTION EDUCATION OFFERED.— 

21 The type of prevention education, information, 

22 or training offered to incarcerated persons and 

23 correctional facility staff regarding sexual vio24 lence and the spread of STIs, including whether 

25 such education, information, or training— 


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1 (i) constitutes comprehensive sexuality 

2 education; 

3 (ii) is compulsory for new incarcerated 

4 persons and for new staff; and 

5 (iii) is offered on an ongoing basis. 

6 (E) STI TESTING.—Whether the correc7 tional facility tests incarcerated persons for 

8 STIs or gives them the option to undergo such 

9 testing— 

10 (i) at intake; 

11 (ii) on a regular basis; and 

12 (iii) prior to release. 

13 (F) STI TEST RESULTS.—The number of 

14 incarcerated persons who are tested for STIs 

15 and the outcome of such tests at each correc16 tional facility, disaggregated to include results 

17 for— 

18 (i) the type of sexually transmitted in19 fection tested for; 

20 (ii) the race and/or ethnicity of indi21 viduals tested; 

22 (iii) the age of individuals tested; and 

23 (iv) the gender of individuals tested. 

24 (G) PRERELEASE REFERRAL POLICY.— 

25 Whether incarcerated persons are informed 


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1 prior to release about STI-related services or 

2 other health services in their communities, in3 cluding free and low-cost counseling and treat4 ment options. 

5 (H) PRERELEASE REFERRALS MADE.— 

6 The number of referrals to community-based 

7 organizations or public health facilities offering 

8 STI-related or other health services provided to 

9 incarcerated persons prior to release, and the 

10 type of counseling or treatment for which the 

11 referral was made. 

12 (I) REINSTATEMENT OF MEDICAID BENE13 FITS.—Whether the correctional facility assists 

14 incarcerated persons that were enrolled in the 

15 State Medicaid program prior to their incarcer16 ation, in reinstating their enrollment upon re17 lease and whether such individuals receive refer18 rals as provided by subparagraph (G) to entities 

19 that accept the State Medicaid program, includ20 ing if applicable— 

21 (i) the number of such individuals, in22 cluding those diagnosed with the human 

23 immunodeficiency virus, that have been re24 instated; 


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1 (ii) a list of obstacles to reinstating 

2 enrollment or to making determinations of 

3 eligibility for reinstatement, if any; and 

4 (iii) the number of individuals denied 

5 enrollment. 

6 (J) OTHER ACTIONS TAKEN.—Whether the 

7 correctional facility has taken any other action, 

8 in conjunction with community organizations or 

9 otherwise, to reduce the prevalence and spread 

10 of STIs in that facility. 

11 (2) PRIVACY.—In conducting the survey, the 

12 Attorney General shall not request or retain the 

13 identity of any person who has sought or been of14 fered counseling, treatment, testing, or prevention 

15 education information regarding an STI (including 

16 information about sexual barrier protection devices), 

17 or who has tested positive for an STI. 

18 (3) REPORT.—The Attorney General shall 

19 transmit to Congress and make publicly available 

20 the results of the survey required under paragraph 

21 (1), both for the Nation as a whole and 

22 disaggregated as to each State and each correctional 

23 facility. To the maximum extent possible, the Attor24 ney General shall issue the first report no later than 


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1 1 year after the date of enactment of this Act and 

2 shall issue reports annually thereafter for 5 years. 

3 (d) STRATEGY.— 

4 (1) DIRECTIVE TO ATTORNEY GENERAL.—The 

5 Attorney General, in consultation with the Secretary 

6 of Health and Human Services, State officials, and 

7 community organizations, shall develop and imple8 ment a 5-year strategy to reduce the prevalence and 

9 spread of STIs in Federal and State correctional fa10 cilities. To the maximum extent possible, the strat11 egy shall be developed, transmitted to Congress, and 

12 made publicly available no later than 180 days after 

13 the transmission of the first report required under 

14 subsection (c)(3). 

15 (2) CONTENTS OF STRATEGY.—The strategy 

16 shall include the following: 

17 (A) PREVENTION EDUCATION.—A plan for 

18 improving prevention education, information, 

19 and training offered to incarcerated persons 

20 and correctional facility staff, including infor21 mation and training on sexual violence and the 

22 spread of STIs, and comprehensive sexuality 

23 education. 

24 (B) SEXUAL BARRIER PROTECTION DEVICE

25 ACCESS.—A plan for expanding access to sexual 


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1 barrier protection devices in correctional facili2 ties. 

3 (C) SEXUAL VIOLENCE REDUCTION.—A 

4 plan for reducing the incidence of sexual vio5 lence among incarcerated persons and correc6 tional facility staff, developed in consultation 

7 with the National Prison Rape Elimination 

8 Commission. 

9 (D) COUNSELING AND SUPPORTIVE SERV10 ICES.—A plan for expanding access to coun11 seling and supportive services related to STIs in 

12 correctional facilities. 

13 (E) TESTING.—A plan for testing incarcer14 ated persons for STIs during intake, during 

15 regular health exams, and prior to release, and 

16 that— 

17 (i) is conducted in accordance with 

18 guidelines established by the Centers for 

19 Disease Control and Prevention; 

20 (ii) includes pretest counseling; 

21 (iii) requires that incarcerated persons 

22 are notified of their option to decline test23 ing at any time; 


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1 (iv) requires that incarcerated persons 

2 are confidentially notified of their test re3 sults in a timely manner; and 

4 (v) ensures that incarcerated persons 

5 testing positive for STIs receive post-test 

6 counseling, care, treatment, and supportive 

7 services. 

8 (F) TREATMENT.—A plan for ensuring 

9 that correctional facilities have the necessary 

10 medicine and equipment to treat and monitor 

11 STIs and for ensuring that incarcerated per12 sons living with or testing positive for STIs re13 ceive and have access to care and treatment 

14 services. 

15 (G) STRATEGIES FOR DEMOGRAPHIC

16 GROUPS.—A plan for developing and imple17 menting culturally appropriate, sensitive, and 

18 specific strategies to reduce the spread of STIs 

19 among demographic groups heavily impacted by 

20 STIs. 

21 (H) LINKAGES WITH COMMUNITIES AND

22 FACILITIES.—A plan for establishing and 

23 strengthening linkages to local communities and 

24 health facilities that— 


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1 (i) provide counseling, testing, care, 

2 and treatment services; 

3 (ii) may receive persons recently re4 leased from incarceration who are living 

5 with STIs; and 

6 (iii) accept payment through the State 

7 Medicaid program. 

8 (I) ENROLLMENT IN STATE MEDICAID

9 PROGRAMS.—Plans to ensure that incarcerated 

10 persons who were— 

11 (i) enrolled in their State Medicaid 

12 program prior to incarceration in a correc13 tional facility are automatically reenrolled 

14 in such program upon their release; and 

15 (ii) not enrolled in their State Med16 icaid program prior to incarceration, but 

17 who are diagnosed with the human im18 munodeficiency virus while incarcerated in 

19 a correctional facility, are automatically 

20 enrolled in such program upon their re21 lease. 

22 (J) OTHER PLANS.—Any other plans de23 veloped by the Attorney General for reducing 

24 the spread of STIs or improving the quality of 

25 health care in correctional facilities. 


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1 (K) MONITORING SYSTEM.—A monitoring 

2 system that establishes performance goals re3 lated to reducing the prevalence and spread of 

4 STIs in correctional facilities and which, where 

5 feasible, expresses such goals in quantifiable 

6 form. 

7 (L) MONITORING SYSTEM PERFORMANCE

8 INDICATORS.—Performance indicators that 

9 measure or assess the achievement of the per10 formance goals described in subparagraph (K). 

11 (M) COST ESTIMATE.—A detailed estimate 

12 of the funding necessary to implement the 

13 strategy at the Federal and State levels for all 

14 5 years, including the amount of funds required 

15 by community organizations to implement the 

16 parts of the strategy in which they take part. 

17 (3) REPORT.—The Attorney General shall 

18 transmit to Congress and make publicly available an 

19 annual progress report regarding the implementation 

20 and effectiveness of the strategy described in para21 graph (1). The progress report shall include an eval22 uation of the implementation of the strategy using 

23 the monitoring system and performance indicators 

24 provided for in subparagraphs (K) and (L) of para25 graph (2). 


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1 (e) AUTHORIZATION OF APPROPRIATIONS.— 

2 (1) IN GENERAL.—There are authorized to be 

3 appropriated such sums as may be necessary to 

4 carry out this section for each of fiscal years 2019 

5 through 2023. 

6 (2) AVAILABILITY OF FUNDS.—Amounts made 

7 available under paragraph (1) are authorized to re8 main available until expended. 

9 (f) DEFINITIONS.—For the purposes of this section: 

10 (1) COMMUNITY ORGANIZATION.—The term 

11 ‘‘community organization’’ means a public health 

12 care facility or a nonprofit organization which pro13 vides health- or STI-related services according to es14 tablished public health standards. 

15 (2) COMPREHENSIVE SEXUALITY EDUCATION.— 

16 The term ‘‘comprehensive sexuality education’’ 

17 means sexuality education that includes information 

18 about abstinence and about the proper use and dis19 posal of sexual barrier protection devices and which 

20 is— 

21 (A) evidence-based; 

22 (B) medically accurate; 

23 (C) age and developmentally appropriate; 

24 (D) gender and identity sensitive; 


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1 (E) culturally and linguistically appro2 priate; and 

3 (F) structured to promote critical thinking, 

4 self-esteem, respect for others, and the develop5 ment of healthy attitudes and relationships. 

6 (3) CORRECTIONAL FACILITY.—The term ‘‘cor7 rectional facility’’ means any prison, penitentiary, 

8 adult detention facility, juvenile detention facility, 

9 jail, or other facility to which persons may be sent 

10 after conviction of a crime or act of juvenile delin11 quency within the United States. 

12 (4) INCARCERATED PERSON.—The term ‘‘incar13 cerated person’’ means any person who is serving a 

14 sentence in a correctional facility after conviction of 

15 a crime. 

16 (5) SEXUALLY TRANSMITTED INFECTION.—The 

17 term ‘‘sexually transmitted infection’’ or ‘‘STI’’ 

18 means any disease or infection that is commonly 

19 transmitted through sexual activity, including HIV/ 

20 AIDS, gonorrhea, chlamydia, syphilis, genital her21 pes, viral hepatitis, and human papillomavirus. 

22 (6) SEXUAL BARRIER PROTECTION DEVICE.— 

23 The term ‘‘sexual barrier protection device’’ means 

24 any FDA-approved physical device which has not 

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1 ability of STI transmission or infection between sex2 ual partners, including female condoms, male 

3 condoms, and dental dams. 

4 (7) STATE.—The term ‘‘State’’ includes the 

5 District of Columbia, American Samoa, the Com6 monwealth of the Northern Mariana Islands, Guam, 

7 Puerto Rico, and the United States Virgin Islands. 

8 SEC. 757. AUTOMATIC REINSTATEMENT OR ENROLLMENT 

9 IN MEDICAID FOR PEOPLE WHO TEST POSI10 TIVE FOR HIV BEFORE REENTERING COMMU11 NITIES. 

12 (a) IN GENERAL.—Section 1902(e) of the Social Se13 curity Act (42 U.S.C. 1396a(e)) is amended by adding at 

14 the end the following: 

15 ‘‘(15) ENROLLMENT OF EX-OFFENDERS.— 

16 ‘‘(A) AUTOMATIC ENROLLMENT OR REIN17 STATEMENT.— 

18 ‘‘(i) IN GENERAL.—The State plan 

19 shall provide for the automatic enrollment 

20 or reinstatement of enrollment of an eligi21 ble individual— 

22 ‘‘(I) if such individual is sched23 uled to be released from a public insti24 tution due to the completion of senVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00646 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 tence, not less than 30 days prior to 

2 the scheduled date of the release; and 

3 ‘‘(II) if such individual is to be 

4 released from a public institution on 

5 parole or on probation, as soon as 

6 possible after the date on which the 

7 determination to release such indi8 vidual was made, and before the date 

9 such individual is released. 

10 ‘‘(ii) EXCEPTION.—If a State makes a 

11 determination that an individual is not eli12 gible to be enrolled under the State plan— 

13 ‘‘(I) on or before the date by 

14 which the individual would be enrolled 

15 under clause (i), such clause shall not 

16 apply to such individual; or 

17 ‘‘(II) after such date, the State 

18 may terminate the enrollment of such 

19 individual. 

20 ‘‘(B) RELATIONSHIP OF ENROLLMENT TO

21 PAYMENT FOR SERVICES.— 

22 ‘‘(i) IN GENERAL.—Subject to sub23 paragraph (A)(ii), an eligible individual 

24 who is enrolled, or whose enrollment is re25 instated, under subparagraph (A) shall be 


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1 eligible for medical assistance that is pro2 vided after the date that the eligible indi3 vidual is released from the public institu4 tion. 

5 ‘‘(ii) RELATIONSHIP TO PAYMENT

6 PROHIBITION FOR INMATES.—No provision 

7 of this paragraph may be construed to per8 mit payment for care or services for which 

9 payment is excluded under section 

10 1905(a)(3)(A). 

11 ‘‘(C) TREATMENT OF CONTINUOUS ELIGI12 BILITY.— 

13 ‘‘(i) SUSPENSION FOR INMATES.—Any 

14 period of continuous eligibility under this 

15 title shall be suspended on the date an in16 dividual enrolled under this title becomes 

17 an inmate of a public institution (except as 

18 a patient of a medical institution). 

19 ‘‘(ii) DETERMINATION OF REMAINING

20 PERIOD.—Notwithstanding any changes to 

21 State law related to continuous eligibility 

22 during the time that an individual is an in23 mate of a public institution (except as a 

24 patient of a medical institution), subject to 

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1 vidual who was subject to a suspension 

2 under clause (i), on the date that such in3 dividual is released from a public institu4 tion the suspension of continuous eligibility 

5 under such clause shall be lifted for a pe6 riod that is equal to the time remaining in 

7 the period of continuous eligibility for such 

8 individual on the date that such period was 

9 suspended under such clause. 

10 ‘‘(iii) EXCEPTION.—If a State makes 

11 a determination that an individual is not 

12 eligible to be enrolled under the State 

13 plan— 

14 ‘‘(I) on or before the date that 

15 the suspension of continuous eligibility 

16 is lifted under clause (ii), such clause 

17 shall not apply to such individual; or 

18 ‘‘(II) after such date, the State 

19 may terminate the enrollment of such 

20 individual. 

21 ‘‘(D) AUTOMATIC ENROLLMENT OR REIN22 STATEMENT OF ENROLLMENT DEFINED.—For 

23 purposes of this paragraph, the term ‘automatic 

24 enrollment or reinstatement of enrollment’ 

25 means that the State determines eligibility for 


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1 medical assistance under the State plan without 

2 a program application from, or on behalf of, the 

3 eligible individual, but an individual can only be 

4 automatically enrolled in the State Medicaid 

5 plan if the individual affirmatively consents to 

6 being enrolled through affirmation in writing, 

7 by telephone, orally, through electronic signa8 ture, or through any other means specified by 

9 the Secretary. 

10 ‘‘(E) ELIGIBLE INDIVIDUAL DEFINED.— 

11 For purposes of this paragraph, the term ‘eligi12 ble individual’ means an individual who is an 

13 inmate of a public institution (except as a pa14 tient in a medical institution)— 

15 ‘‘(i) who was enrolled under the State 

16 plan for medical assistance immediately be17 fore becoming an inmate of such an insti18 tution; or 

19 ‘‘(ii) who is diagnosed with human im20 munodeficiency virus.’’. 

21 (b) SUPPLEMENTAL FUNDING FOR STATE IMPLE22 MENTATION OF AUTOMATIC REINSTATEMENT OF MED23 ICAID BENEFITS.— 

24 (1) IN GENERAL.—Subject to paragraph (6), 

25 for each State for which the Secretary of Health and 


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1 Human Services has approved an application under 

2 paragraph (3), the Federal matching payments (in3 cluding payments based on the Federal medical as4 sistance percentage) made to such State under sec5 tion 1903 of the Social Security Act (42 U.S.C. 

6 1396b) shall be increased by 5.0 percentage points 

7 for payments to the State for the activities per8 mitted under paragraph (2) or a period of one year. 

9 (2) USE OF FUNDS.—A State may only use in10 creased matching payments authorized under para11 graph (1)— 

12 (A) to strengthen the State’s enrollment 

13 and administrative resources for the purpose of 

14 improving processes for enrolling (or reinstating 

15 the enrollment of) eligible individuals (as such 

16 term is defined in subparagraph (E) of para17 graph (15) of section 1902(e) of the Social Se18 curity Act (as amended by subsection (a))); and 

19 (B) for medical assistance (as such term is 

20 defined in section 1905(a) of the Social Secu21 rity Act) provided to such eligible individuals. 

22 (3) APPLICATION AND AGREEMENT.—The Sec23 retary may only make payments to a State in the in24 creased amount if— 


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1 (A) the State has amended the State plan 

2 under section 1902(e) of the Social Security 

3 Act to incorporate the requirements of para4 graph (15) of such section (as added by sub5 section (a)); 

6 (B) the State has submitted an application 

7 to the Secretary that includes a plan for imple8 menting the requirements of section 

9 1902(e)(15) of the Social Security Act under 

10 the State’s amended State plan before the end 

11 of the 90-day period beginning on the date that 

12 the State receives increased matching payments 

13 under paragraph (1); 

14 (C) the State’s application meets the satis15 faction of the Secretary; and 

16 (D) the State enters an agreement with 

17 the Secretary that states that— 

18 (i) the State will only use the in19 creased matching funds for the uses per20 mitted under paragraph (2); and 

21 (ii) at the end of the period under 

22 paragraph (1), the State will submit to the 

23 Secretary, and make publicly available, a 

24 report that contains the information re25 quired under paragraph (4). 


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1 (4) REQUIRED REPORT INFORMATION.—The in2 formation that is required in the report under para3 graph (3)(D)(ii) includes— 

4 (A) the results of an evaluation of the im5 pact of the implementation of the requirements 

6 of section 1902(e)(15) of the Social Security 

7 Act on improving the State’s processes for en8 rolling of individuals who are released from 

9 public institutions into the Medicaid program; 

10 (B) the number of individuals who were 

11 automatically enrolled (or whose enrollment is 

12 reinstated) under such section 1902(e)(15) dur13 ing the period under paragraph (1); and 

14 (C) any other information that is required 

15 by the Secretary. 

16 (5) INCREASE IN CAP ON MEDICAID PAYMENTS

17 TO TERRITORIES.—Subject to paragraph (6), the 

18 amounts otherwise determined for Puerto Rico, the 

19 United States Virgin Islands, Guam, the Northern 

20 Mariana Islands, and American Samoa under sub21 sections (f) and (g) of section 1108 of the Social Se22 curity Act (42 U.S.C. 1308) shall each be increased 

23 by the necessary amount to allow for the increase in 

24 the Federal matching payments under paragraph 

25 (1), but only for the period under such paragraph 


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1 for such State. In the case of such an increase for 

2 a territory, subsection (a)(1) of such section 1108 

3 shall be applied without regard to any increase in 

4 payment made to the territory under part E of title 

5 IV of such Act that is attributable to the increase 

6 in Federal medical assistance percentage effected 

7 under paragraph (1) for the territory. 

8 (6) LIMITATIONS.— 

9 (A) TIMING.—With respect to a State, at 

10 the end of the period under paragraph (1), no 

11 increased matching payments may be made to 

12 such State under this subsection. 

13 (B) MAINTENANCE OF ELIGIBILITY.— 

14 (i) IN GENERAL.—Subject to clause 

15 (ii), a State is not eligible for an increase 

16 in its Federal matching payments under 

17 paragraph (1), or an increase in a cap 

18 amount under paragraph (5), if eligibility 

19 standards, methodologies, or procedures 

20 under its State plan under title XIX of the 

21 Social Security Act (including any waiver 

22 under such title or under section 1115 of 

23 such Act (42 U.S.C. 1315)) are more re24 strictive than the eligibility standards, 

25 methodologies, or procedures, respectively, 


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1 under such plan (or waiver) as in effect on 

2 the date of enactment of this Act. 

3 (ii) STATE REINSTATEMENT OF ELIGI4 BILITY PERMITTED.—A State that has re5 stricted eligibility standards, methodolo6 gies, or procedures under its State plan 

7 under title XIX of the Social Security Act 

8 (including any waiver under such title or 

9 under section 1115 of such Act (42 U.S.C. 

10 1315)) after the date of enactment of this 

11 Act, is no longer ineligible under subpara12 graph (A) beginning with the first calendar 

13 quarter in which the State has reinstated 

14 eligibility standards, methodologies, or pro15 cedures that are no more restrictive than 

16 the eligibility standards, methodologies, or 

17 procedures, respectively, under such plan 

18 (or waiver) as in effect on such date. 

19 (C) NO WAIVER AUTHORITY.—The Sec20 retary may not waive the application of this 

21 subsection under section 1115 of the Social Se22 curity Act or otherwise. 

23 (D) LIMITATION OF MATCHING PAYMENTS

24 TO 100 PERCENT.—In no case shall an increase 

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1 section result in Federal matching payments 

2 that exceed 100 percent. 

3 (c) EFFECTIVE DATE.— 

4 (1) IN GENERAL.—Except as provided in para5 graph (2), the amendments made by subsection (a) 

6 shall take effect 180 days after the date of the en7 actment of this Act and shall apply to services fur8 nished on or after such date. 

9 (2) RULE FOR CHANGES REQUIRING STATE

10 LEGISLATION.—In the case of a State plan for med11 ical assistance under title XIX of the Social Security 

12 Act which the Secretary of Health and Human Serv13 ices determines requires State legislation (other than 

14 legislation appropriating funds) in order for the plan 

15 to meet the additional requirement imposed by the 

16 amendments made by this section, the State plan 

17 shall not be regarded as failing to comply with the 

18 requirements of such title solely on the basis of its 

19 failure to meet this additional requirement before 

20 the first day of the first calendar quarter beginning 

21 after the close of the first regular session of the 

22 State legislature that begins after the date of the en23 actment of this Act. For purposes of the previous 

24 sentence, in the case of a State that has a 2-year 

25 legislative session, each year of such session shall be 


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1 deemed to be a separate regular session of the State 

2 legislature. 

3 SEC. 758. STOP AIDS IN PRISON. 

4 (a) SHORT TITLE.—This section may be cited as the 

5 ‘‘Stop AIDS in Prison Act’’. 

6 (b) IN GENERAL.—The Bureau of Prisons (herein7 after in this section referred to as the ‘‘Bureau’’) shall 

8 develop a comprehensive policy to provide HIV testing, 

9 treatment, and prevention for inmates within the correc10 tional setting and upon reentry. 

11 (c) PURPOSE.—The purposes of this policy shall be 

12 as follows: 

13 (1) To stop the spread of HIV/AIDS among in14 mates. 

15 (2) To protect prison guards and other per16 sonnel from HIV/AIDS infection. 

17 (3) To provide comprehensive medical treat18 ment to inmates who are living with HIV/AIDS. 

19 (4) To promote HIV/AIDS awareness and pre20 vention among inmates. 

21 (5) To encourage inmates to take personal re22 sponsibility for their health. 

23 (6) To reduce the risk that inmates will trans24 mit HIV/AIDS to other persons in the community 

25 following their release from prison. 


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1 (d) CONSULTATION.—The Bureau shall consult with 

2 appropriate officials of the Department of Health and 

3 Human Services, the Office of National Drug Control Pol4 icy, the Office of National AIDS Policy, and the Centers 

5 for Disease Control and Prevention regarding the develop6 ment of this policy. 

7 (e) TIME LIMIT.—The Bureau shall draft appro8 priate regulations to implement this policy not later than 

9 1 year after the date of the enactment of this Act. 

10 (f) REQUIREMENTS FOR POLICY.—The policy created 

11 under subsection (b) shall provide for the following: 

12 (1) TESTING AND COUNSELING UPON IN13 TAKE.— 

14 (A) Health care personnel shall provide 

15 routine HIV testing to all inmates as a part of 

16 a comprehensive medical examination imme17 diately following admission to a facility. Health 

18 care personnel need not provide routine HIV 

19 testing to an inmate who is transferred to a fa20 cility from another facility if the inmate’s med21 ical records are transferred with the inmate and 

22 indicate that the inmate has been tested pre23 viously. 

24 (B) To all inmates admitted to a facility 

25 prior to the effective date of this policy, health 


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1 care personnel shall provide routine HIV testing 

2 within no more than 6 months. HIV testing for 

3 these inmates may be performed in conjunction 

4 with other health services provided to these in5 mates by health care personnel. 

6 (C) All HIV tests under this paragraph 

7 shall comply with the opt-out provision. 

8 (2) PRE-TEST AND POST-TEST COUNSELING.— 

9 Health care personnel shall provide confidential pre10 test and post-test counseling to all inmates who are 

11 tested for HIV. Counseling may be included with 

12 other general health counseling provided to inmates 

13 by health care personnel. 

14 (3) HIV/AIDS PREVENTION EDUCATION.— 

15 (A) Health care personnel shall improve 

16 HIV/AIDS awareness through frequent edu17 cational programs for all inmates. HIV/AIDS 

18 educational programs may be provided by com19 munity-based organizations, local health depart20 ments, and inmate peer educators. 

21 (B) HIV/AIDS educational materials shall 

22 be made available to all inmates at orientation, 

23 at health care clinics, at regular educational 

24 programs, and prior to release. Both written 


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1 and audiovisual materials shall be made avail2 able to all inmates. 

3 (C)(i) The HIV/AIDS educational pro4 grams and materials under this paragraph shall 

5 include information on— 

6 (I) modes of transmission, including 

7 transmission through tattooing, sexual con8 tact, and intravenous drug use; 

9 (II) prevention methods; 

10 (III) treatment; and 

11 (IV) disease progression. 

12 (ii) The programs and materials shall be 

13 culturally sensitive, written or designed for low14 literacy levels, available in a variety of lan15 guages, and present scientifically accurate in16 formation in a clear and understandable man17 ner. 

18 (4) HIV TESTING UPON REQUEST.— 

19 (A) Health care personnel shall allow in20 mates to obtain HIV tests upon request once 

21 per year or whenever an inmate has a reason to 

22 believe the inmate may have been exposed to 

23 HIV. Health care personnel shall, both orally 

24 and in writing, inform inmates, during orientaVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00660 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 tion and periodically throughout incarceration, 

2 of their right to obtain HIV tests. 

3 (B) Health care personnel shall encourage 

4 inmates to request HIV tests if the inmate is 

5 sexually active, has been raped, uses intra6 venous drugs, receives a tattoo, or if the inmate 

7 is concerned that the inmate may have been ex8 posed to HIV/AIDS. 

9 (C) An inmate’s request for an HIV test 

10 shall not be considered an indication that the 

11 inmate has put him/herself at risk of infection 

12 and/or committed a violation of prison rules. 

13 (5) HIV TESTING OF PREGNANT WOMAN.— 

14 (A) Health care personnel shall provide 

15 routine HIV testing to all inmates who become 

16 pregnant. 

17 (B) All HIV tests under this paragraph 

18 shall comply with the opt-out provision. 

19 (6) COMPREHENSIVE TREATMENT.— 

20 (A) Health care personnel shall provide all 

21 inmates who test positive for HIV— 

22 (i) timely, comprehensive medical 

23 treatment; 

24 (ii) confidential counseling on man25 aging their medical condition and preVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00661 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 venting its transmission to other persons; 

2 and 

3 (iii) voluntary partner notification 

4 services. 

5 (B) Health care provided under this para6 graph shall be consistent with current Depart7 ment of Health and Human Services guidelines 

8 and standard medical practice. Health care per9 sonnel shall discuss treatment options, the im10 portance of adherence to antiretroviral therapy, 

11 and the side effects of medications with inmates 

12 receiving treatment. 

13 (C) Health care personnel and pharmacy 

14 personnel shall ensure that the facility for15 mulary contains all Food and Drug Administra16 tion-approved medications necessary to provide 

17 comprehensive treatment for inmates living with 

18 HIV/AIDS, and that the facility maintains ade19 quate supplies of such medications to meet in20 mates’ medical needs. Health care personnel 

21 and pharmacy personnel shall also develop and 

22 implement automatic renewal systems for these 

23 medications to prevent interruptions in care. 

24 (D) Correctional staff, health care per25 sonnel, and pharmacy personnel shall develop 


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1 and implement distribution procedures to en2 sure timely and confidential access to medica3 tions. 

4 (7) PROTECTION OF CONFIDENTIALITY.— 

5 (A) Health care personnel shall develop 

6 and implement procedures to ensure the con7 fidentiality of inmate tests, diagnoses, and 

8 treatment. Health care personnel and correc9 tional staff shall receive regular training on the 

10 implementation of these procedures. Penalties 

11 for violations of inmate confidentiality by health 

12 care personnel or correctional staff shall be 

13 specified and strictly enforced. 

14 (B) HIV testing, counseling, and treat15 ment shall be provided in a confidential setting 

16 where other routine health services are provided 

17 and in a manner that allows the inmate to re18 quest and obtain these services as routine med19 ical services. 

20 (8) TESTING, COUNSELING, AND REFERRAL

21 PRIOR TO REENTRY.— 

22 (A) Health care personnel shall provide 

23 routine HIV testing to all inmates no more 

24 than 3 months prior to their release and re25 entry into the community. Inmates who are alVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00663 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 ready known to be infected need not be tested 

2 again. This requirement may be waived if an in3 mate’s release occurs without sufficient notice 

4 to the Bureau to allow health care personnel to 

5 perform a routine HIV test and notify the in6 mate of the results. 

7 (B) All HIV tests under this paragraph 

8 shall comply with the opt-out provision. 

9 (C) To all inmates who test positive for 

10 HIV and all inmates who already are known to 

11 have HIV/AIDS, health care personnel shall 

12 provide— 

13 (i) confidential prerelease counseling 

14 on managing their medical condition in the 

15 community, accessing appropriate treat16 ment and services in the community, and 

17 preventing the transmission of their condi18 tion to family members and other persons 

19 in the community; 

20 (ii) referrals to appropriate health 

21 care providers and social service agencies 

22 in the community that meet the inmate’s 

23 individual needs, including voluntary part24 ner notification services and prevention 


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1 counseling services for people living with 

2 HIV/AIDS; and 

3 (iii) a 30-day supply of any medically 

4 necessary medications the inmate is cur5 rently receiving. 

6 (9) OPT-OUT PROVISION.—Inmates shall have 

7 the right to refuse routine HIV testing. Inmates 

8 shall be informed both orally and in writing of this 

9 right. Oral and written disclosure of this right may 

10 be included with other general health information 

11 and counseling provided to inmates by health care 

12 personnel. If an inmate refuses a routine test for 

13 HIV, health care personnel shall make a note of the 

14 inmate’s refusal in the inmate’s confidential medical 

15 records. However, the inmate’s refusal shall not be 

16 considered a violation of prison rules or result in dis17 ciplinary action. Any reference in this section to the 

18 ‘‘opt-out provision’’ shall be deemed a reference to 

19 the requirement of this paragraph. 

20 (10) EXCLUSION OF TESTS PERFORMED UNDER

21 SECTION 4014(b) FROM THE DEFINITION OF ROU22 TINE HIV TESTING.—HIV testing of an inmate 

23 under section 4014(b) of title 18, United States 

24 Code, is not routine HIV testing for the purposes of 

25 the opt-out provision. Health care personnel shall 


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1 document the reason for testing under section 

2 4014(b) of title 18, United States Code, in the in3 mate’s confidential medical records. 

4 (11) TIMELY NOTIFICATION OF TEST RE5 SULTS.—Health care personnel shall provide timely 

6 notification to inmates of the results of HIV tests. 

7 (g) CHANGES IN EXISTING LAW.— 

8 (1) SCREENING IN GENERAL.—Section 4014(a) 

9 of title 18, United States Code, is amended— 

10 (A) by striking ‘‘for a period of 6 months 

11 or more’’; 

12 (B) by striking ‘‘, as appropriate,’’; and 

13 (C) by striking ‘‘if such individual is deter14 mined to be at risk for infection with such virus 

15 in accordance with the guidelines issued by the 

16 Bureau of Prisons relating to infectious disease 

17 management’’ and inserting ‘‘unless the indi18 vidual declines. The Attorney General shall also 

19 cause such individual to be so tested before re20 lease unless the individual declines.’’. 

21 (2) INADMISSIBILITY OF HIV TEST RESULTS IN

22 CIVIL AND CRIMINAL PROCEEDINGS.—Section 

23 4014(d) of title 18, United States Code, is amended 

24 by inserting ‘‘or under the Stop AIDS in Prison 

25 Act’’ after ‘‘under this section’’. 


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1 (3) SCREENING AS PART OF ROUTINE SCREEN2 ING.—Section 4014(e) of title 18, United States 

3 Code, is amended by adding at the end the fol4 lowing: ‘‘Such rules shall also provide that the initial 

5 test under this section be performed as part of the 

6 routine health screening conducted at intake.’’. 

7 (h) REPORTING REQUIREMENTS.— 

8 (1) REPORT ON HEPATITIS, LIVER, AND OTHER

9 DISEASES.—Not later than 1 year after the date of 

10 the enactment of this Act, the Bureau shall provide 

11 a report to the Congress on Bureau policies and pro12 cedures to provide testing, treatment, and prevention 

13 education programs for hepatitis, liver failure, and 

14 other liver-related diseases transmitted through sex15 ual activity, intravenous drug use, or other means. 

16 The Bureau shall consult with appropriate officials 

17 of the Department of Health and Human Services, 

18 the Office of National Drug Control Policy, the Of19 fice of National AIDS Policy, and the Centers for 

20 Disease Control and Prevention regarding the devel21 opment of this report. 

22 (2) ANNUAL REPORTS.— 

23 (A) GENERALLY.—Not later than 2 years 

24 after the date of the enactment of this Act, and 

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1 port to Congress on the incidence among in2 mates of diseases transmitted through sexual 

3 activity and intravenous drug use. 

4 (B) MATTERS PERTAINING TO VARIOUS

5 DISEASES.—Reports under paragraph (1) shall 

6 discuss— 

7 (i) the incidence among inmates of 

8 HIV/AIDS, hepatitis, and other diseases 

9 transmitted through sexual activity and in10 travenous drug use; and 

11 (ii) updates on Bureau testing, treat12 ment, and prevention education programs 

13 for these diseases. 

14 (C) MATTERS PERTAINING TO HIV/AIDS

15 ONLY.—Reports under paragraph (1) shall also 

16 include— 

17 (i) the number of inmates who tested 

18 positive for HIV upon intake; 

19 (ii) the number of inmates who tested 

20 positive prior to reentry; 

21 (iii) the number of inmates who were 

22 not tested prior to reentry because they 

23 were released without sufficient notice; 

24 (iv) the number of inmates who opted25 out of taking the test; 


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1 (v) the number of inmates who were 

2 tested under section 4014(b) of title 18, 

3 United States Code; and 

4 (vi) the number of inmates under 

5 treatment for HIV/AIDS. 

6 (D) CONSULTATION.—The Bureau shall 

7 consult with appropriate officials of the Depart8 ment of Health and Human Services, the Office 

9 of National Drug Control Policy, the Office of 

10 National AIDS Policy, and the Centers for Dis11 ease Control and Prevention regarding the de12 velopment of reports under paragraph (1). 

13 SEC. 759. SUPPORT DATA SYSTEM REVIEW AND INDICA14 TORS FOR MONITORING HIV CARE. 

15 The Secretary of Health and Human Services, in col16 laboration with the Assistant Secretary for Health, the Di17 rector of the Office of HIV/AIDS and Infectious Disease 

18 Policy, the Director of the Centers for Disease Control and 

19 Prevention, the Administrator of the Substance Abuse and 

20 Mental Health Services Administration, the Director of 

21 the Department of Housing and Urban Development, the 

22 Director of the Office of AIDS Research, the Adminis23 trator of the Health Resources and Services Administra24 tion, and the Administrator of the Centers for Medicare 

25 & Medicaid Services, shall expand and coordinate efforts 


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1 to align metrics across agencies and modify Federal data 

2 systems, to— 

3 (1) adopt the Institute of Medicine’s clinical 

4 HIV care indicators as the core metrics for moni5 toring the quality of HIV care, mental health, sub6 stance abuse, and supportive services; 

7 (2) better enable assessment of the impact of 

8 the National HIV/AIDS Strategy and the Patient 

9 Protection and Affordable Care Act on improving 

10 HIV/AIDS care and access to supportive services for 

11 individuals with HIV; 

12 (3) expand the demographic data elements to be 

13 captured by Federal data systems relevant to HIV 

14 care to permit calculation of the indicators for sub15 groups of the population of people with diagnosed 

16 HIV infection, including— 

17 (A) age; 

18 (B) race; 

19 (C) ethnicity; 

20 (D) sex (assigned at birth); 

21 (E) gender identity; 

22 (F) sexual orientation; 

23 (G) current geographic marker of resi24 dence; 

25 (H) income or poverty level; and 


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1 (I) primary means of reimbursement for 

2 medical services (including Medicaid, Medicare, 

3 the Ryan White HIV/AIDS Program, private 

4 insurance, health maintenance organizations, 

5 and no coverage); and 

6 (4) streamline data collection and systematically 

7 review all existing reporting requirements for feder8 ally funded HIV/AIDS programs to ensure that only 

9 essential data are collected. 

10 SEC. 760. TRANSFER OF FUNDS FOR IMPLEMENTATION OF 

11 NATIONAL HIV/AIDS STRATEGY. 

12 Title II of the Public Health Service Act (42 U.S.C. 

13 202 et seq.) is amended by inserting after section 241 the 

14 following: 

15 ‘‘SEC. 241A. TRANSFER OF FUNDS FOR IMPLEMENTATION 

16 OF NATIONAL HIV/AIDS STRATEGY. 

17 ‘‘(a) TRANSFER AUTHORIZATION.—Of the discre18 tionary appropriations made available to the Department 

19 of Health and Human Services for any fiscal year for pro20 grams and activities that, as determined by the Secretary 

21 of Health and Human Services, pertain to HIV/AIDS, the 

22 Secretary, in coordination with the Director of the Office 

23 of National HIV/AIDS Policy, may transfer up to 1 per24 cent of such appropriations to the Office of the Assistant 


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1 Secretary for Health for implementation of the National 

2 HIV/AIDS Strategy. 

3 ‘‘(b) CONGRESSIONAL NOTIFICATION.—Not less than 

4 30 days before making any transfer under this section, 

5 the Secretary shall give notice of the transfer to the Con6 gress. 

7 ‘‘(c) DEFINITIONS.—In this section: 

8 ‘‘(1) HIV/AIDS.—The term ‘HIV/AIDS’ has 

9 the meaning given to such term in section 2689. 

10 ‘‘(2) NATIONAL HIV/AIDS STRATEGY.—The 

11 term ‘National HIV/AIDS Strategy’ means the Na12 tional HIV/AIDS Strategy for the United States 

13 issued by the President in July 2010 and includes 

14 any subsequent revisions to such Strategy.’’. 

15 SEC. 761. REPORT ON THE IMPLEMENTATION OF GOAL 4 

16 (IMPROVED COORDINATION) OF THE NA17 TIONAL HIV/AIDS STRATEGY. 

18 (a) REPORT REQUIRED.—The President, in consulta19 tion with the heads of all relevant Federal departments 

20 and agencies including the Department of Education, the 

21 Department of Health and Human Services, the Depart22 ment of Housing and Urban Development, the Depart23 ment of Justice, the Department of Labor, the Depart24 ment of Veteran Affairs, and the Social Security Adminis25 tration, shall transmit to the Congress and make publicly 


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1 available a report on the status of implementation of Goal 

2 4 of the National HIV/AIDS Strategy. 

3 (b) CONTENTS.—The report required by subsection 

4 (a) shall include a description, an analysis, and an evalua5 tion of— 

6 (1) the extent to which the National HIV/AIDS 

7 Strategy has improved coordination of efforts, en8 hanced capacity, and strengthened infrastructure in 

9 order to maximize the effective delivery of HIV/ 

10 AIDS prevention, care, and treatment services at the 

11 community level, including coordination— 

12 (A) within and among Federal agencies 

13 and departments; 

14 (B) between the Federal Government and 

15 State and local governments and health depart16 ments; 

17 (C) between the Federal Government and 

18 nonprofit foundations and civil society organiza19 tions, including community- and faith-based or20 ganizations focused on addressing the issue of 

21 HIV/AIDS; and 

22 (D) between the Federal Government and 

23 private businesses; and 

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1 ships with civil society organizations, including 

2 community- and faith-based organizations, in order 

3 to implement the National HIV/AIDS Strategy and 

4 achieve its goals. 

5 (c) DEFINITION.—In this section, the term ‘‘National 

6 HIV/AIDS Strategy’’ means the National HIV/AIDS 

7 Strategy for the United States issued by the President in 

8 July 2010, the revision to such Strategy issued in July 

9 2015, and any subsequent revisions to such Strategy. 

10 Subtitle F—Diabetes 

11 SEC. 771. RESEARCH, TREATMENT, AND EDUCATION. 

12 Subpart 3 of part C of title IV of the Public Health 

13 Service Act (42 U.S.C. 285c et seq.) is amended by adding 

14 at the end the following new section: 

15 ‘‘SEC. 434B. DIABETES IN MINORITY POPULATIONS. 

16 ‘‘(a) IN GENERAL.—The Director of NIH shall ex17 pand, intensify, and support ongoing research and other 

18 activities with respect to prediabetes and diabetes, particu19 larly type 2, in minority populations. 

20 ‘‘(b) RESEARCH.— 

21 ‘‘(1) DESCRIPTION.—Research under subsection 

22 (a) shall include investigation into— 

23 ‘‘(A) the causes of diabetes, including so24 cioeconomic, geographic, clinical, environmental, 

25 genetic, and other factors that may contribute 


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1 to increased rates of diabetes in minority popu2 lations; and 

3 ‘‘(B) the causes of increased incidence of 

4 diabetes complications in minority populations, 

5 and possible interventions to decrease such inci6 dence. 

7 ‘‘(2) INCLUSION OF MINORITY PARTICIPANTS.— 

8 In conducting and supporting research described in 

9 subsection (a), the Director of NIH shall seek to in10 clude minority participants as study subjects in clin11 ical trials. 

12 ‘‘(c) REPORT; COMPREHENSIVE PLAN.— 

13 ‘‘(1) IN GENERAL.—The Diabetes Mellitus 

14 Interagency Coordinating Committee shall— 

15 ‘‘(A) prepare and submit to the Congress, 

16 not later than 6 months after the date of enact17 ment of this section, a report on Federal re18 search and public health activities with respect 

19 to prediabetes and diabetes in minority popu20 lations; and 

21 ‘‘(B) develop and submit to the Congress, 

22 not later than 1 year after the date of enact23 ment of this section, an effective and com24 prehensive Federal plan (including all appro25 priate Federal health programs) to address 


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1 prediabetes and diabetes in minority popu2 lations. 

3 ‘‘(2) CONTENTS.—The report under paragraph 

4 (1)(A) shall at minimum address each of the fol5 lowing: 

6 ‘‘(A) Research on diabetes and prediabetes 

7 in minority populations, including such research 

8 on— 

9 ‘‘(i) genetic, behavioral, and environ10 mental factors; and 

11 ‘‘(ii) prevention and complications 

12 among individuals within these populations 

13 who have already developed diabetes. 

14 ‘‘(B) Surveillance and data collection on 

15 diabetes and prediabetes in minority popu16 lations, including with respect to— 

17 ‘‘(i) efforts to better determine the 

18 prevalence of diabetes among Asian-Amer19 ican and Pacific Islander subgroups; and 

20 ‘‘(ii) efforts to coordinate data collec21 tion on the American Indian population. 

22 ‘‘(C) Community-based interventions to ad23 dress diabetes and prediabetes targeting minor24 ity populations, including— 


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1 ‘‘(i) the evidence base for such inter2 ventions; 

3 ‘‘(ii) the cultural appropriateness of 

4 such interventions; and 

5 ‘‘(iii) efforts to educate the public on 

6 the causes and consequences of diabetes. 

7 ‘‘(D) Education and training programs for 

8 health professionals (including community 

9 health workers) on the prevention and manage10 ment of diabetes and its related complications 

11 that is supported by the Health Resources and 

12 Services Administration, including such pro13 grams supported by— 

14 ‘‘(i) the National Health Service 

15 Corps; or 

16 ‘‘(ii) the community health centers 

17 program under section 330. 

18 ‘‘(d) EDUCATION.—The Director of NIH shall— 

19 ‘‘(1) through the National Institute on Minority 

20 Health and Health Disparities and the National Di21 abetes Education Program— 

22 ‘‘(A) make grants to programs funded 

23 under section 464z–4 (relating to centers of ex24 cellence) for the purpose of establishing a men25 toring program for health care professionals to 


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1 be more involved in weight counseling, obesity 

2 research, and nutrition; and 

3 ‘‘(B) provide for the participation of mi4 nority health professionals in diabetes-focused 

5 research programs; and 

6 ‘‘(2) make grants for programs to establish a 

7 pipeline from high school to professional school that 

8 will increase minority representation in diabetes-fo9 cused health fields by expanding Minority Access to 

10 Research Careers (MARC) program internships and 

11 mentoring opportunities for recruitment. 

12 ‘‘(e) DEFINITIONS.—For purposes of this section: 

13 ‘‘(1) DIABETES MELLITUS INTERAGENCY CO14 ORDINATING COMMITTEE.—The ‘Diabetes Mellitus 

15 Interagency Coordinating Committee’ means the Di16 abetes Mellitus Interagency Coordinating Committee 

17 established under section 429. 

18 ‘‘(2) MINORITY POPULATION.—The term ‘mi19 nority population’ means a racial and ethnic minor20 ity group, as defined in section 1707.’’. 

21 SEC. 772. RESEARCH, EDUCATION, AND OTHER ACTIVITIES. 

22 Part B of title III of the Public Health Service Act 

23 (42 U.S.C. 243 et seq.) is amended by inserting after sec24 tion 317X of such Act, as added, the following section: 


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1 ‘‘SEC. 317Y. DIABETES IN MINORITY POPULATIONS. 

2 ‘‘(a) RESEARCH AND OTHER ACTIVITIES.— 

3 ‘‘(1) IN GENERAL.—The Secretary, acting 

4 through the Director of the Centers for Disease 

5 Control and Prevention, shall conduct and support 

6 research and public health activities with respect to 

7 diabetes in minority populations. 

8 ‘‘(2) CERTAIN ACTIVITIES.—Activities under 

9 paragraph (1) regarding diabetes in minority popu10 lations shall include the following: 

11 ‘‘(A) Further enhancing the National 

12 Health and Nutrition Examination Survey by 

13 oversampling Asian American, Native Hawai14 ian, and Pacific Islanders in appropriate geo15 graphic areas to better determine the preva16 lence of diabetes in such populations as well as 

17 to improve the data collection of diabetes pene18 tration disaggregated into major ethnic groups 

19 within such populations. The Secretary shall en20 sure that any such oversampling does not re21 duce the oversampling of other minority popu22 lations including African-American and Latino 

23 populations. 

24 ‘‘(B) Through the Division of Diabetes 

25 Translation— 


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1 ‘‘(i) providing for prevention research 

2 to better understand how to influence 

3 health care systems changes to improve 

4 quality of care being delivered to such pop5 ulations; 

6 ‘‘(ii) carrying out model demonstra7 tion projects to design, implement, and 

8 evaluate effective diabetes prevention and 

9 control interventions for minority popu10 lations, including culturally appropriate 

11 community-based interventions; 

12 ‘‘(iii) developing and implementing a 

13 strategic plan to reduce diabetes in minor14 ity populations through applied research to 

15 reduce disparities and culturally and lin16 guistically appropriate community-based 

17 interventions; 

18 ‘‘(iv) supporting, through the national 

19 diabetes prevention program under section 

20 399V–3, diabetes prevention program sites 

21 in underserved regions highly impacted by 

22 diabetes; and 

23 ‘‘(v) implementing, through the na24 tional diabetes prevention program under 

25 section 399V–3, a demonstration program 


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1 developing new metrics measuring health 

2 outcomes related to diabetes that can be 

3 stratified by specific minority populations. 

4 ‘‘(b) EDUCATION.—The Secretary, acting through 

5 the Director of the Centers for Disease Control and Pre6 vention, shall direct the Division of Diabetes Translation 

7 to conduct and support both programs to educate the pub8 lic on diabetes in minority populations and programs to 

9 educate minority populations about the causes and effects 

10 of diabetes. 

11 ‘‘(c) DIABETES; HEALTH PROMOTION, PREVENTION

12 ACTIVITIES, AND ACCESS.—The Secretary, acting through 

13 the Director of the Centers for Disease Control and Pre14 vention and the National Diabetes Education Program, 

15 shall conduct and support programs to educate specific 

16 minority populations through culturally appropriate and 

17 linguistically appropriate information campaigns about 

18 prevention of, and managing, diabetes. 

19 ‘‘(d) DEFINITION.—For purposes of this section, the 

20 term ‘minority population’ means a racial and ethnic mi21 nority group, as defined in section 1707.’’. 

22 SEC. 773. RESEARCH, EDUCATION, AND OTHER ACTIVITIES. 

23 Part P of title III of the Public Health Service Act 

24 (42 U.S.C. 280g et seq.), as amended, is further amended 

25 by adding at the end the following new section: 


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1 ‘‘SEC. 399V–9. PROGRAMS TO EDUCATE HEALTH PRO2 VIDERS ON THE CAUSES AND EFFECTS OF DI3 ABETES IN MINORITY POPULATIONS. 

4 ‘‘(a) IN GENERAL.—The Secretary, acting through 

5 the Director of the Health Resources and Services Admin6 istration, shall conduct and support programs described 

7 in subsection (b) to educate health professionals on the 

8 causes and effects of diabetes in minority populations. 

9 ‘‘(b) PROGRAMS.—Programs described in this sub10 section, with respect to education on diabetes in minority 

11 populations, shall include the following: 

12 ‘‘(1) Giving priority, under the primary care 

13 training and enhancement program under section 

14 747— 

15 ‘‘(A) to awarding grants to focus on or ad16 dress diabetes; and 

17 ‘‘(B) to adding minority populations to the 

18 list of vulnerable populations that should be 

19 served by such grants. 

20 ‘‘(2) Providing additional funds for the Health 

21 Careers Opportunity Program, the Centers for Ex22 cellence, and the Minority Faculty Fellowship Pro23 gram to partner with the Office of Minority Health 

24 under section 1707 and the National Institutes of 

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1 ties focused on diabetes treatment and care within 

2 underserved regions highly impacted by diabetes. 

3 ‘‘(3) Developing a diabetes focus within, and 

4 providing additional funds for, the National Health 

5 Service Corps Scholarship Program— 

6 ‘‘(A) to place individuals in areas that are 

7 disproportionately affected by diabetes and to 

8 provide diabetes treatment and care in such 

9 areas; and 

10 ‘‘(B) to provide such individuals continuing 

11 medical education specific to diabetes care.’’. 

12 SEC. 774. RESEARCH, EDUCATION, AND OTHER ACTIVITIES. 

13 Part P of title III of the Public Health Service Act 

14 (42 U.S.C. 280g et seq.), as amended, is further amended 

15 by adding at the end the following section: 

16 ‘‘SEC. 399V–10. RESEARCH, EDUCATION, AND OTHER ACTIVI17 TIES REGARDING DIABETES IN AMERICAN IN18 DIAN POPULATIONS. 

19 ‘‘In addition to activities under sections 399V–6 and 

20 434B, the Secretary, acting through the Indian Health 

21 Service and in collaboration with other appropriate Fed22 eral agencies, shall— 

23 ‘‘(1) conduct and support research and other 

24 activities with respect to diabetes; and 


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1 ‘‘(2) coordinate the collection of data on clini2 cally and culturally appropriate diabetes treatment, 

3 care, prevention, and services by health care profes4 sionals to the American Indian population.’’. 

5 SEC. 775. UPDATED REPORT ON HEALTH DISPARITIES. 

6 The Secretary of Health and Human Services shall 

7 seek to enter into an arrangement with the Institute of 

8 Medicine under which the Institute will— 

9 (1) not later than 1 year after the date of en10 actment of this Act, submit to the Congress an up11 dated version of the Institute’s 2002 report entitled 

12 ‘‘Unequal Treatment: Confronting Racial and Ethnic 

13 Disparities in Health Care’’; and 

14 (2) in such updated version, address how racial 

15 and ethnic health disparities have changed since the 

16 publication of the original report. 

17 Subtitle G—Lung Disease 

18 SEC. 776. EXPANSION OF THE NATIONAL ASTHMA EDU19 CATION AND PREVENTION PROGRAM. 

20 (a) FINDINGS.—The Congress finds as follows: 

21 (1) The prevalence of asthma has increased 

22 since 1980 and affects 25 million Americans. 

23 (2) Significant disparities in asthma morbidity 

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1 ticularly for low-income and minority populations, 

2 particularly African Americans and Puerto Ricans. 

3 (3) African-American children are twice as like4 ly to have asthma as White children. 

5 (4) In 2010, almost 4.5 million non-Hispanic 

6 African Americans reported having asthma. African 

7 Americans with asthma are three times as likely to 

8 visit the emergency department and twice as likely 

9 to get hospitalized as White patients with asthma. 

10 (5) Puerto Ricans are 3.4 times as likely to die 

11 from asthma compared with all other Hispanic or 

12 Latino groups. Overall Hispanic Americans are 30 

13 percent more likely to be hospitalized for asthma 

14 than non-Hispanic Whites. 

15 (6) More than 65 percent of adults with asthma 

16 are women. 

17 (b) IN GENERAL.—Not later than 2 years after the 

18 date of the enactment of this Act, the Secretary of Health 

19 and Human Services shall convene a working group com20 prised of patient groups, nonprofit organizations, medical 

21 societies, and other relevant governmental and nongovern22 mental entities, including those that participate in the Na23 tional Asthma Education and Prevention Program, to de24 velop a report to Congress that— 


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1 (1) catalogs, with respect to asthma prevention, 

2 management, and surveillance— 

3 (A) the activities of the Federal Govern4 ment, including identifying all Federal pro5 grams that carry out asthma-related activities, 

6 as well as assessment of the progress of the 

7 Federal Government and States, with respect to 

8 achieving the goals of the Healthy People 2020 

9 initiative; and 

10 (B) the activities of other entities that par11 ticipate in the program, including nonprofit or12 ganizations, patient advocacy groups, and med13 ical societies; and 

14 (2) makes recommendations for the future di15 rection of asthma activities, in consultation with re16 searchers from the National Institutes of Health and 

17 other member bodies of the National Asthma Edu18 cation and Prevention Program who are qualified to 

19 review and analyze data and evaluate interventions, 

20 including— 

21 (A) a description of how the Federal Gov22 ernment may better coordinate and improve its 

23 response to asthma including identifying any 

24 barriers that may exist; 


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1 (B) a description of how the Federal Gov2 ernment may continue, expand, and improve its 

3 private-public partnerships with respect to asth4 ma including identifying any barriers that may 

5 exist; 

6 (C) identification of steps that may be 

7 taken to reduce the— 

8 (i) morbidity, mortality, and overall 

9 prevalence of asthma; 

10 (ii) financial burden of asthma on so11 ciety; 

12 (iii) burden of asthma on dispropor13 tionately affected areas, particularly those 

14 in medically underserved populations (as 

15 defined in section 330(b)(3) of the Public 

16 Health Service Act (42 U.S.C. 

17 254b(b)(3))); and 

18 (iv) burden of asthma as a chronic 

19 disease; 

20 (D) identification of programs and policies 

21 that have achieved the steps described in sub22 paragraph (C), and steps that may be taken to 

23 expand such programs and policies to benefit 

24 larger populations; and 


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1 (E) recommendations for future research 

2 and interventions. 

3 (c) REPORT TO CONGRESS.—At the end of the 5-year 

4 period following the submission of the report under this 

5 section, the National Asthma Education and Prevention 

6 Program shall evaluate the analyses and recommendations 

7 under such report and determine whether a new report 

8 to the Congress is necessary, and make appropriate rec9 ommendations to the Congress. 

10 SEC. 777. ASTHMA-RELATED ACTIVITIES OF THE CENTERS 

11 FOR DISEASE CONTROL AND PREVENTION. 

12 Section 317I of the Public Health Service Act (42 

13 U.S.C. 247b–10) is amended to read as follows: 

14 ‘‘SEC. 317I. ASTHMA-RELATED ACTIVITIES OF THE CENTERS 

15 FOR DISEASE CONTROL AND PREVENTION. 

16 ‘‘(a) PROGRAM FOR PROVIDING INFORMATION AND

17 EDUCATION TO THE PUBLIC.—The Secretary, acting 

18 through the Director of the Centers for Disease Control 

19 and Prevention, shall collaborate with State and local 

20 health departments to conduct activities, including the 

21 provision of information and education to the public re22 garding asthma including— 

23 ‘‘(1) deterring the harmful consequences of un24 controlled asthma; and 


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1 ‘‘(2) disseminating health education and infor2 mation regarding prevention of asthma episodes and 

3 strategies for managing asthma. 

4 ‘‘(b) DEVELOPMENT OF STATE ASTHMA PLANS.— 

5 The Secretary, acting through the Director of the Centers 

6 for Disease Control and Prevention, shall collaborate with 

7 State and local health departments to develop State plans 

8 incorporating public health responses to reduce the burden 

9 of asthma, particularly regarding disproportionately af10 fected populations. 

11 ‘‘(c) COMPILATION OF DATA.—The Secretary, acting 

12 through the Director of the Centers for Disease Control 

13 and Prevention, shall, in cooperation with State and local 

14 public health officials— 

15 ‘‘(1) conduct asthma surveillance activities to 

16 collect data on the prevalence and severity of asth17 ma, the effectiveness of public health asthma inter18 ventions, and the quality of asthma management, in19 cluding— 

20 ‘‘(A) collection of household data on the 

21 local burden of asthma; 

22 ‘‘(B) surveillance of health care facilities; 

23 and 

24 ‘‘(C) collection of data not containing indi25 vidually identifiable information from electronic 


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1 health records or other electronic communica2 tions; 

3 ‘‘(2) compile and annually publish data regard4 ing the prevalence and incidence of childhood asth5 ma, the child mortality rate, and the number of hos6 pital admissions and emergency department visits by 

7 children associated with asthma nationally and in 

8 each State and at the county level by age, sex, race, 

9 and ethnicity, as well as lifetime and current preva10 lence; and 

11 ‘‘(3) compile and annually publish data regard12 ing the prevalence and incidence of adult asthma, 

13 the adult mortality rate, and the number of hospital 

14 admissions and emergency department visits by 

15 adults associated with asthma nationally and in each 

16 State and at the county level by age, sex, race, eth17 nicity, industry, and occupation, as well as lifetime 

18 and current prevalence. 

19 ‘‘(d) COORDINATION OF DATA COLLECTION.—The 

20 Director of the Centers for Disease Control and Preven21 tion, in conjunction with State and local health depart22 ments, shall coordinate data collection activities under 

23 subsection (c)(2) so as to maximize comparability of re24 sults. 


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1 ‘‘(e) COLLABORATION.—The Centers for Disease 

2 Control and Prevention are encouraged to collaborate with 

3 national, State, and local nonprofit organizations to pro4 vide information and education about asthma, and to 

5 strengthen such collaborations when possible. 

6 ‘‘(f) ADDITIONAL FUNDING.—In addition to any 

7 other authorization of appropriations that is available to 

8 the Centers for Disease Control and Prevention for the 

9 purpose of carrying out this section, there are authorized 

10 to be appropriated to such Centers such sums as may be 

11 necessary for each of fiscal years 2019 through 2023 for 

12 the purpose of carrying out this section.’’. 

13 SEC. 778. INFLUENZA AND PNEUMONIA VACCINATION CAM14 PAIGN. 

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

16 Human Services shall— 

17 (1) enhance the annual campaign by the De18 partment of Health and Human Services to increase 

19 the number of people vaccinated each year for influ20 enza and pneumonia; and 

21 (2) include in such campaign the use of written 

22 educational materials, public service announcements, 

23 physician education, and any other means which the 

24 Secretary deems effective. 


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1 (b) MATERIALS AND ANNOUNCEMENTS.—In carrying 

2 out the annual campaign described in subsection (a), the 

3 Secretary of Health and Human Services shall ensure 

4 that— 

5 (1) educational materials and public service an6 nouncements are readily and widely available in 

7 communities experiencing disparities in the incidence 

8 and mortality rates of influenza and pneumonia; and 

9 (2) the campaign uses targeted, culturally ap10 propriate messages and messengers to reach under11 served communities. 

12 (c) AUTHORIZATION OF APPROPRIATIONS.—There 

13 are authorized to be appropriated to carry out this section 

14 such sums as may be necessary for each of fiscal years 

15 2019 through 2023. 

16 SEC. 779. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 

17 ACTION PLAN. 

18 (a) FINDINGS.—The Congress finds as follows: 

19 (1) Chronic obstructive pulmonary disease 

20 (‘‘COPD’’) refers to chronic bronchitis and emphy21 sema, incurable diseases that make it difficult to ex22 hale all the air from one’s lungs, and that can cause 

23 persistent coughing, shortness of breath, and spu24 tum. 


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1 (2) COPD exacerbations—episodes of acute dif2 ficulty breathing and moderate to severe fatigue— 

3 are dangerous, and their treatment often requires 

4 hospitalization. 

5 (3) While smoking is the primary risk factor for 

6 COPD, other risk factors include air pollution, occu7 pational exposures, heredity, a history of childhood 

8 respiratory infections, and socioeconomic status. 

9 (4) Over 13.5 million United States adults are 

10 estimated to have COPD. 

11 (5) COPD is the third-leading cause of death in 

12 America, claiming over 134,000 lives in 2010. 

13 (6) Since 2000, deaths for women with COPD 

14 have exceeded deaths in men. 

15 (7) Although African Americans have a lower 

16 prevalence of COPD in the United States, research17 ers have shown that African Americans may be 

18 underdiagnosed. Furthermore, research has shown 

19 that African Americans develop COPD with less cu20 mulative smoke exposure and at a younger age. 

21 (b) IN GENERAL.—The Director of the Centers for 

22 Disease Control and Prevention shall conduct, support, 

23 and expand public health strategies, prevention, diagnosis, 

24 surveillance, and public and professional awareness activi25 ties regarding chronic obstructive pulmonary disease. 


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1 (c) NATIONAL ACTION PLAN.— 

2 (1) DEVELOPMENT.—Not later than 2 years 

3 after the date of the enactment of this Act, the Di4 rector of the National Heart, Lung, and Blood Insti5 tute, in consultation with the Director of the Centers 

6 for Disease Control and Prevention, shall develop a 

7 national action plan to address chronic obstructive 

8 pulmonary disease in the United States with partici9 pation from patients, caregivers, health profes10 sionals, patient advocacy organizations, researchers, 

11 providers, public health professionals, and other 

12 stakeholders. 

13 (2) CONTENTS.—At a minimum, such plan 

14 shall include recommendations for— 

15 (A) public health interventions for the pur16 pose of implementation of the national plan; 

17 (B) biomedical, health services, and public 

18 health research on chronic obstructive pul19 monary disease; and 

20 (C) inclusion of chronic obstructive pul21 monary disease in the health data collections of 

22 all Federal agencies. 

23 (3) CONSIDERATION.—In developing such plan, 

24 the Director of the National Heart, Lung, and Blood 

25 Institute shall consider the recommendations and 


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1 findings of the Institute of Medicine in the report 

2 entitled ‘‘A Nationwide Framework for Surveillance 

3 of Cardiovascular and Chronic Lung Diseases’’ (July 

4 22, 2011). 

5 (d) CHRONIC DISEASE PREVENTION PROGRAMS.— 

6 The Director of the National Heart, Lung, and Blood In7 stitute shall carry out the following: 

8 (1) Conduct public education and awareness ac9 tivities with patient and professional organizations 

10 to stimulate earlier diagnosis and improve patient 

11 outcomes from treatment of chronic obstructive pul12 monary disease. To the extent known and relevant, 

13 such public education and awareness activities shall 

14 reflect differences in chronic obstructive pulmonary 

15 disease by cause (tobacco, environmental, occupa16 tional, biological, and genetic) and include a focus 

17 on outreach to undiagnosed and, as appropriate, mi18 nority populations. 

19 (2) Supplement and expand upon the activities 

20 of the National Heart, Lung, and Blood Institute by 

21 making grants to nonprofit organizations, State and 

22 local jurisdictions, and Indian Tribes for the purpose 

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1 pacted communities, through public health interven2 tions and related activities. 

3 (3) Coordinate with the Centers for Disease 

4 Control and Prevention, the Indian Health Service, 

5 the Health Resources and Services Administration, 

6 and the Department of Veterans Affairs to develop 

7 pilot programs to demonstrate best practices for the 

8 diagnosis and management of chronic obstructive 

9 pulmonary disease. 

10 (4) Develop improved techniques and identify 

11 best practices, in coordination with the Secretary of 

12 Veterans Affairs, for assisting chronic obstructive 

13 pulmonary disease patients to successfully stop 

14 smoking, including identification of subpopulations 

15 with different needs. Initiatives under this para16 graph may include research to determine whether 

17 successful smoking cessation strategies are different 

18 for chronic obstructive pulmonary disease patients 

19 compared to such strategies for patients with other 

20 chronic diseases. 

21 (e) ENVIRONMENTAL AND OCCUPATIONAL HEALTH

22 PROGRAMS.—The Director of the Centers for Disease 

23 Control and Prevention shall— 

24 (1) support research into the environmental and 

25 occupational causes and biological mechanisms that 


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1 contribute to chronic obstructive pulmonary disease; 

2 and 

3 (2) develop and disseminate public health inter4 ventions that will lessen the impact of environmental 

5 and occupational causes of chronic obstructive pul6 monary disease. 

7 (f) DATA COLLECTION.—Not later than 180 days 

8 after the enactment of this Act, the Director of the Na9 tional Heart, Lung, and Blood Institute and the Director 

10 of the Centers for Disease Control and Prevention, acting 

11 jointly, shall assess the depth and quality of information 

12 on chronic obstructive pulmonary disease that is collected 

13 in surveys and population studies conducted by the Cen14 ters for Disease Control and Prevention, including wheth15 er there are additional opportunities for information to be 

16 collected in the National Health and Nutrition Examina17 tion Survey, the National Health Interview Survey, and 

18 the Behavioral Risk Factors Surveillance System surveys. 

19 The Director of the National Heart, Lung, and Blood In20 stitute shall include the results of such assessment in the 

21 national action plan under subsection (b). 

22 (g) AUTHORIZATION OF APPROPRIATIONS.—There 

23 are authorized to be appropriated to carry out this section 

24 such sums as may be necessary for each of fiscal years 

25 2019 through 2023. 


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1 Subtitle H—Tuberculosis 

2 SEC. 781. ELIMINATION OF ALL FORMS OF TUBERCULOSIS. 

3 (a) SHORT TITLE.—This subtitle be cited as the 

4 ‘‘End Tuberculosis Act’’. 

5 (b) FINDINGS.—The Congress makes the following 

6 findings: 

7 (1) In the United States, 9,272 people were di8 agnosed with tuberculosis (referred to in this section 

9 as ‘‘TB’’) in 2016. 

10 (2) Disparities in TB exist and significantly im11 pact minority communities in the United States. The 

12 Centers for Disease Control and Prevention (re13 ferred to in this section as ‘‘CDC’’) finds that 87 

14 percent of people diagnosed with TB in 2016 self15 identified as racial and ethnic minorities. 

16 (3) African Americans comprised 21 percent of 

17 people diagnosed with TB during 2016. The popu18 lation-adjusted rate of TB among African Americans 

19 is 1.7 times higher than the national total, and 8.2 

20 times higher than among Whites. 

21 (4) Asian Americans, Native Hawaiians, and 

22 other Pacific Islanders comprised 35 percent of peo23 ple diagnosed with TB during 2016. The population24 adjusted rate of TB among Asian Americans is 6.2 

25 times higher than the national total, and 30 times 


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1 higher than among Whites. The population-adjusted 

2 rate of TB among Native Hawaiians and other Pa3 cific Islanders is 4.8 times higher than the national 

4 total, and 23.2 times higher than among Whites. 

5 (5) Hispanics and Latinos comprised 28 per6 cent of people diagnosed with TB during 2016. The 

7 population-adjusted rate of TB among Hispanics 

8 and Latinos is 1.6 times higher than the national 

9 total, and 7.5 times higher than among Whites. 

10 (6) TB is both preventable and curable, but the 

11 current rate of decline of TB in the United States 

12 remains too slow to achieve TB elimination in this 

13 century. 

14 (7) TB is transmitted through the air when a 

15 person who has TB disease in their lungs coughs or 

16 sneezes. People who are in close proximity to the 

17 person with TB can breathe in the TB bacteria, and 

18 the bacteria will initially settle in their lungs. With19 out proper and timely diagnosis and access to treat20 ment, the TB bacteria may grow and spread to 

21 other parts of their body. 

22 (8) As many as 13,000,000 people in the 

23 United States may have Latent TB Infection (re24 ferred to in this section as ‘‘LTBI’’). People with 

25 LTBI have TB bacteria in their bodies, but their 


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1 immune system is containing the bacteria, and they 

2 are not sick, nor do they have any current risk of 

3 spreading TB to others. LTBI can activate into in4 fectious, life-threatening TB if not treated. Modeling 

5 has shown that eliminating TB is not possible with6 out addressing LTBI. 

7 (9) Comorbidities associated with TB include 

8 cancer, diabetes mellitus, and HIV. People with 

9 these medical conditions and compromised immune 

10 systems are more likely to develop active TB disease 

11 and to have worse outcomes from TB. 

12 (10) Forms of active TB that do not show drug 

13 resistance are classified as Drug-susceptible TB (re14 ferred to in this section as ‘‘DS–TB’’). Drug-resist15 ant TB (referred to in this section as ‘‘DR–TB’’) is 

16 a rising threat to the public health of the United 

17 States. DR–TB that exhibits resistance to two or 

18 more first-line drugs is referred to as multi-drug re19 sistant TB (referred to in this section as ‘‘MDR– 

20 TB’’). MDR–TB that also is resistant to at least 

21 one injectable second-line medication and at least 

22 one fluoroquinolone is classified as extensively drug23 resistant TB (referred to in this section as ‘‘XDR– 

24 TB’’). 


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1 (11) Approximately 78 people in the United 

2 States were diagnosed with MDR–TB in 2016. One 

3 person was diagnosed with XDR–TB in the same 

4 year. 

5 (12) In the United States, direct treatment 

6 costs average $17,000 to treat a patient with DS– 

7 TB, $150,000 to treat a patient with MDR–TB, and 

8 $482,000 to treat a patient with XDR–TB. When 

9 factoring in productivity losses during treatment, 

10 DS–TB averages $46,000, MDR–TB averages 

11 $294,000 and XDR–TB averages $694,000. Treat12 ment is often difficult, with daily complex multi-pill 

13 regimens and injections, with side-effects ranging 

14 from hearing and vision loss to mental health issues. 

15 (13) Recognizing the public health, economic 

16 and societal costs to the threat of MDR–TB, the 

17 National Action Plan to Combat MDR–TB (NAP) 

18 was developed by the White House to provide the 

19 United States with a comprehensive three-pronged 

20 strategy to address MDR–TB by strengthening do21 mestic capacity to combat MDR–TB; improve inter22 national capacity and cooperation to combat MDR– 

23 TB; accelerate basic and applied research and devel24 opment for new therapies, diagnostics and preven25 tion strategies to combat MDR–TB. 


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1 (14) Additional Federal support is necessary to 

2 expand TB control efforts in case finding and treat3 ment to address LTBI in a national prevention ini4 tiative. Key policy and research breakthroughs in5 crease the success of a TB prevention initiative: the 

6 U.S. Preventative Services Task Force recommenda7 tion’s ‘‘B’’ rating, screening for LTBI among high8 risk adults as a covered service increases the likeli9 hood that impacted racial and ethnic minority 

10 groups can get tested for TB; a new, shorter course 

11 treatment regimen (3HP) reduces the length of 

12 treatment for LTBI from every day for 6 to 9 

13 months to one dose per week for 12 weeks, increas14 ing likelihood of treatment completion; and the use 

15 of blood-based diagnostic tests, Interferon-gamma 

16 release assays or IGRAs, increases ability to detect 

17 LTBI among patients in affected communities. 

18 SEC. 782. ADDITIONAL FUNDING FOR STATES IN COM19 BATING AND ELIMINATING TUBERCULOSIS. 

20 Section 317E(f) of the Public Health Act (42 U.S.C. 

21 247b6(f)) is amended by adding at the end the following: 

22 ‘‘(3) ADDITIONAL FUNDING FOR STATES IN

23 COMBATING AND ELIMINATING TUBERCULOSIS.—In 

24 addition to amounts otherwise authorized to be ap25 propriated to carry out this section, there are auVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00702 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 thorized to be appropriated such sums as may be 

2 necessary to carry out sections 247–b(1)(2)(3) for 

3 each of fiscal years 2019 through 2021.’’. 

4 SEC. 783. STRENGTHENING CLINICAL RESEARCH FUNDING 

5 FOR TUBERCULOSIS. 

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

7 Human Services shall expand and intensify support for 

8 current and prospective research activities of the National 

9 Institutes of Health, the Biomedical Advanced Research 

10 and Development Authority, and the Centers for Disease 

11 Control and Prevention Division of Tuberculosis Elimi12 nation to develop new therapeutics, diagnostics, vaccines, 

13 and other prevention modalities in addressing all forms 

14 of tuberculosis (in this section referred to as ‘‘TB’’). 

15 (b) INCLUDED RESEARCH ACTIVITIES.—Research 

16 activities under subsection (a) shall include— 

17 (1) research to develop novel, safe drugs and 

18 drug regimens for the treatment of TB, including in 

19 adolescent and pediatric populations and in pregnant 

20 and lactating women; 

21 (2) research to develop rapid diagnostic tests 

22 for all forms of TB, including diagnostics that can 

23 be used for pediatric populations and people living 

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1 monary TB and drug resistance, and diagnostics 

2 that can be used at the point of care; 

3 (3) research to advance basic knowledge of the 

4 pathogenesis of TB and its major comorbidities, in5 cluding HIV and diabetes mellitus; 

6 (4) research to improve knowledge and under7 standings of the role of latency in TB and the fac8 tors that increase the risk of latent TB infection 

9 progressing to active, symptomatic TB disease; 

10 (5) awarding grants and contracts to specifi11 cally develop new and needed vaccines to address 

12 TB; 

13 (6) awarding grants and contracts to support 

14 the training and development of clinical researchers 

15 whose research improves the landscape of tools to 

16 combat TB; and 

17 (7) awarding grants and contracts to support 

18 capacity-building and develop clinical trial site infra19 structure in the United States and in TB endemic 

20 countries to support the aforementioned research ac21 tivities. 

22 Subtitle I—Osteoarthritis and 

23 Musculoskeletal Diseases 

24 SEC. 785. FINDINGS. 

25 The Congress finds as follows: 


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1 (1) Eighty percent of African-American women 

2 and nearly 74 percent of Hispanic men are either 

3 overweight or obese, speeding the onset and progres4 sion of arthritis. 

5 (2) Arthritis affects 46 million Americans, and 

6 that number will rise to 67 million by the year 2030. 

7 (3) Twenty-seven million Americans suffer from 

8 osteoarthritis, the most common form of arthritis, 

9 making it the leading cause of disability in the 

10 United States. Osteoarthritis is sometimes referred 

11 to as degenerative joint disease. 

12 (4) Obesity accelerates the onset of arthritis: 70 

13 percent of obese adults with mild osteoarthritis of 

14 the knee at age 60 will develop advanced end-stage 

15 disease by age 80. In contrast, just 43 percent of 

16 nonobese adults will have end-stage disease over the 

17 same time period. 

18 (5) Arthritis affects one in five Americans, and 

19 is the single greatest cause of chronic pain and dis20 ability in the United States. 

21 (6) Women, African Americans, and Hispanics 

22 have more severe arthritis and functional limitations. 

23 These same individuals are more likely to be obese, 

24 diabetic, and have higher incidence of heart dis25 ease—medical conditions that can be improved with 


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1 physical activity. Instead of moving; however, these 

2 groups have an inactivity rate of 40 to 50 percent, 

3 which continues to increase. 

4 (7) Arthritis costs $128 billion a year, including 

5 $81 billion in direct costs (medical) and $47 billion 

6 in indirect costs (lost earnings). Each year, $309 bil7 lion in direct and indirect costs is lost due to dis8 parities in osteoarthritis and musculoskeletal dis9 eases. 

10 (8) Obesity and other chronic health conditions 

11 exacerbate the debilitating impact of arthritis, lead12 ing to inactivity, loss of independence, and a per13 petual cycle of comorbid chronic conditions. 

14 (9) Sixty-one percent of arthritis sufferers are 

15 women, and women represent 64 percent of an esti16 mated 43 million annual visits to physicians’ offices 

17 and outpatient clinics where arthritis was the pri18 mary diagnosis. Women also represented 60 percent 

19 of approximately 1 million hospitalizations that oc20 curred in 2003 for which arthritis was the primary 

21 diagnosis. 

(10) Women ages 65 and older have up to 21 22 ⁄2

23 times more disabilities than men of the same age. 

24 Higher rates of obesity and arthritis among this 

25 group explained up to 48 percent of the gender gap 


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1 in disability, above all other common chronic health 

2 conditions. 

3 (11) The primary indication for total knee 

4 arthroplasty (TKA), also known as knee replace5 ment, is relief of significant, disabling pain caused 

6 by severe arthritis. 

7 (12) Knee replacement is surgery for people 

8 with severe knee damage. Knee replacement can re9 lieve pain and allow you to be more active. When 

10 you have a total knee replacement, the surgeon re11 moves damaged cartilage and bone from the surface 

12 of your knee joint and replaces them with a man13 made surface of metal and plastic. In a partial knee 

14 replacement, the surgeon only replaces one part of 

15 your knee joint. 

16 (13) Total hip replacement, also called total hip 

17 arthroplasty (THA), is used if your hip pain inter18 feres with daily activities and more conservative 

19 treatments have not helped. Arthritis damage is the 

20 most common reason to need hip replacement. 

21 (14) The odds of a family practice physician 

22 recommending TKA to a male patient with moderate 

23 arthritis are twice that of a female patient, while the 

24 odds of an orthopaedic surgeon recommending TKA 


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1 to a male patient with moderate arthritis are 22 

2 times that of a female patient. 

3 (15) African Americans with doctor-diagnosed 

4 arthritis have a higher prevalence of severe pain at5 tributable to arthritis, compared with Whites (34.0 

6 percent versus 22.6 percent). African Americans, 

7 compared to Whites, report a higher proportion of 

8 work limitations (39.5 percent versus 28.0 percent) 

9 and a higher prevalence of arthritis-attributable 

10 work limitation (6.6 percent versus 4.6 percent). 

11 (16) Hispanics are 50 percent more likely than 

12 non-Hispanic Whites to report needing assistance 

13 with at least one instrumental activity of daily living 

14 and to have difficulty walking. 

15 (17) African Americans and Hispanics were 1.3 

16 times more likely to have activity limitation, 1.6 

17 times more likely to have work limitations, and 1.9 

18 times more likely to have severe joint pain than 

19 Whites. 

20 (18) In 2003, the Institute of Medicine reported 

21 that the rates of TKA and THA among African22 American and Hispanic patients are significantly 

23 lower than for Whites—even for those with equitable 

24 health care coverage such as through Medicare or 

25 the Department of Veterans Affairs. 


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1 (19) According to the Centers for Disease Con2 trol and Prevention, in 2000, African-American 

3 Medicare enrollees were 37 percent less likely than 

4 White Medicare enrollees to undergo total knee re5 placements. In 2006, the disparity increased to 39 

6 percent. 

7 (20) Even after adjusting for insurance and 

8 health access, Hispanics and African Americans are 

9 almost 50 percent less likely to undergo total knee 

10 replacement than Whites. 

11 SEC. 786. OSTEOARTHRITIS AND OTHER MUSCULO12 SKELETAL HEALTH-RELATED ACTIVITIES OF 

13 THE CENTERS FOR DISEASE CONTROL AND 

14 PREVENTION. 

15 (a) EDUCATION AND AWARENESS ACTIVITIES.—The 

16 Secretary of Health and Human Services, acting through 

17 the Director of the Centers for Disease Control and Pre18 vention, shall direct the National Center for Chronic Dis19 ease Prevention and Health Promotion to conduct and ex20 pand the Health Community Program and Arthritis Pro21 gram to educate the public on— 

22 (1) the causes of, preventive health actions for, 

23 and effects of arthritis and other musculoskeletal 

24 conditions in minority patient populations; and 


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1 (2) the effects of such conditions on other 

2 comorbidities including obesity, hypertension, and 

3 cardiovascular disease. 

4 (b) PROGRAMS ON ARTHRITIS AND MUSCULO5 SKELETAL CONDITIONS.—Education and awareness pro6 grams of the Centers for Disease Control and Prevention 

7 on arthritis and other musculoskeletal conditions in minor8 ity communities shall— 

9 (1) be culturally and linguistically appropriate 

10 to minority patients, targeting musculoskeletal 

11 health promotion and prevention programs of each 

12 major ethnic group, including— 

13 (A) Native Americans and Alaska Natives; 

14 (B) Asian Americans; 

15 (C) African Americans/Blacks; 

16 (D) Hispanic/Latino Americans; and 

17 (E) Native Hawaiians and Pacific Island18 ers; and 

19 (2) include public awareness campaigns directed 

20 toward these patient populations that emphasize the 

21 importance of musculoskeletal health, physical activ22 ity, diet and healthy lifestyle, and weight reduction 

23 for overweight and obese patients. 

24 (c) AUTHORIZATION OF APPROPRIATIONS.—To carry 

25 out this section, there are authorized to be appropriated 


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1 such sums as are necessary for fiscal year 2019 and each 

2 subsequent fiscal year. 

3 SEC. 787. GRANTS FOR COMPREHENSIVE OSTEOARTHRITIS 

4 AND MUSCULOSKELETAL DISEASE HEALTH 

5 EDUCATION WITHIN HEALTH PROFESSIONS 

6 SCHOOLS. 

7 (a) PROGRAM AUTHORIZED.—The Secretary of 

8 Health and Human Services (in this section referred to 

9 as the ‘‘Secretary’’), in coordination with the Secretary of 

10 Education, shall award grants, on a competitive basis, to 

11 academic health science centers, health professions 

12 schools, and other institutions of higher education to en13 able such institutions to provide people with comprehen14 sive education on arthritis and musculoskeletal health, 

15 particularly— 

16 (1) obesity-related musculoskeletal diseases; 

17 (2) arthritis and osteoarthritis; 

18 (3) arthritis and musculoskeletal health dispari19 ties; and 

20 (4) the relationship between arthritis and mus21 culoskeletal diseases and metabolic activity, psycho22 logical health, and comorbidities such as diabetes, 

23 cardiovascular disease, and hypertension. 

24 (b) DURATION.—Grants awarded under this section 

25 shall be for a period of 5 years. 


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1 (c) APPLICATIONS.—An academic health science cen2 ter, health professions school, or other institution of high3 er education seeking a grant under this section shall sub4 mit an application to the Secretary at such time, in such 

5 manner, and containing such information as the Secretary 

6 may require. 

7 (d) PRIORITY.—In awarding grants under this sec8 tion, the Secretary shall give priority to an institution of 

9 higher education that— 

10 (1) has an enrollment of needy students, as de11 fined in section 318(b) of the Higher Education Act 

12 of 1965 (20 U.S.C. 1059e(b)); 

13 (2) is a Hispanic-serving institution, as defined 

14 in section 502(a) of such Act (20 U.S.C. 1101a(a)); 

15 (3) is a Tribal College or University, as defined 

16 in section 316(b) of such Act (20 U.S.C. 1059c(b)); 

17 (4) is an Alaska Native-serving institution, as 

18 defined in section 317(b) of such Act (20 U.S.C. 

19 1059d(b)); 

20 (5) is a Native Hawaiian-serving institution, as 

21 defined in section 317(b) of such Act (20 U.S.C. 

22 1059d(b)); 

23 (6) is a Predominately Black Institution, as de24 fined in section 318(b) of such Act (20 U.S.C. 

25 1059e(b)); 


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1 (7) is a Native American-serving, non-Tribal in2 stitution, as defined in section 319(b) of such Act 

3 (20 U.S.C. 1059f(b)); 

4 (8) is an Asian-American and Native American 

5 Pacific Islander-serving institution, as defined in 

6 section 320(b) of such Act (20 U.S.C. 1059g(b)); or 

7 (9) is a minority institution, as defined in sec8 tion 365 of such Act (20 U.S.C. 1067k), with an en9 rollment of needy students, as defined in section 312 

10 of such Act (20 U.S.C. 1058). 

11 (e) USES OF FUNDS.—An institution of higher edu12 cation receiving a grant under this section may use grant 

13 funds to integrate issues relating to comprehensive arthri14 tis and musculoskeletal health into the academic or sup15 port sectors of the institution in order to reach a large 

16 number of students, by carrying out 1 or more of the fol17 lowing activities: 

18 (1) Developing educational content for issues 

19 relating to comprehensive arthritis and musculo20 skeletal health education that will be incorporated 

21 into first-year orientation or core courses. 

22 (2) Creating innovative technology-based ap23 proaches to deliver arthritis and musculoskeletal 

24 health education to students, faculty, and staff. 


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1 (3) Developing and employing peer-outreach 

2 and education programs to generate discussion, edu3 cate, and raise awareness among students about 

4 issues relating to arthritis and musculoskeletal 

5 health disorders, and their relationship to diabetes, 

6 hypertension, cardiovascular disease, psychological 

7 health, and other comorbid conditions. 

8 (f) REPORT TO CONGRESS.— 

9 (1) IN GENERAL.—Not later than 1 year after 

10 the date of the enactment of this Act, and annually 

11 thereafter for a period of 5 years, the Secretary shall 

12 prepare and submit to the appropriate committees of 

13 Congress a report on the activities to provide health 

14 professions students with comprehensive arthritis 

15 and musculoskeletal health education funded under 

16 this section. 

17 (2) REPORT ELEMENTS.—The report described 

18 in paragraph (1) shall include information about— 

19 (A) the number of entities that are receiv20 ing grant funds; 

21 (B) the specific activities supported by 

22 grant funds; 

23 (C) the number of students served by 

24 grant programs; and 

25 (D) the status of program evaluations. 


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1 Subtitle J—Sleep and Circadian 

2 Rhythm Disorders 

3 SEC. 791. SHORT TITLE; FINDINGS. 

4 (a) SHORT TITLE.—This subtitle may be cited as the 

5 ‘‘Sleep and Circadian Rhythm Disorders Health Dispari6 ties Act’’. 

7 (b) FINDINGS.—The Congress finds the following: 

8 (1) Decrements in sleep health such as sleep 

9 apnea, insufficient sleep time, and insomnia, affect 

10 50–70 million United States adults. Twelve to eight11 een million United States adults have sleep apnea, a 

12 chronic disorder characterized by one or more 

13 pauses in breathing which can last from a few sec14 onds to minutes. They may occur 30 times or more 

15 an hour, disrupting sleep and resulting in excessive 

16 daytime sleepiness and loss in productivity. 

17 (2) Seventy percent of high school students are 

18 not getting enough sleep on school nights, while 33 

19 percent of Americans get fewer than 7 hours of sleep 

20 per night, and roughly 6,000 fatal motor vehicle 

21 crashes are caused by drowsy drivers. 

22 (3) Insufficient sleep and insomnia are more 

23 prevalent in women. Women who are pregnant and 

24 have sleep apnea are at an increased risk of cardio25 vascular complications during pregnancy. The imVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00715 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 pact of disparities in sleep health is associated with 

2 a growing number of health problems, including the 

3 following: 

4 (A) Hypertension. 

5 (B) Cancer. 

6 (C) Stroke. 

7 (D) Cardiac arrhythmia. 

8 (E) Chronic heart failure and heart dis9 ease. 

10 (F) Diabetes. 

11 (G) Cognitive functioning and behavior. 

12 (H) Depression and bipolar disorder. 

13 (I) Substance abuse. 

14 (4) A ‘‘sleep disparity’’ exists in that poor sleep 

15 quality is strongly associated with poverty and race. 

16 Factors such as employment, education, and health 

17 status, amongst others, significantly mediated this 

18 effect only in poor subjects, suggesting a differential 

19 vulnerability to these factors in poor relative to 

20 nonpoor individuals in the context of sleep quality. 

21 (5) African Americans sleep worse than Cauca22 sian Americans. African Americans take longer to 

23 fall asleep, report poorer sleep quality, have more 

24 light and less deep sleep, and nap more often and 

25 longer. 


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1 (6) African Americans and individuals in lower 

2 socioeconomic status groups may be at an increased 

3 risk for sleep disturbances and associated health 

4 consequences. 

5 (7) Among young African Americans, the likeli6 hood of having sleep disordered breathing and exhib7 iting risk factors for poor sleep is twice that in 

8 young Caucasians. Frequent snoring is more com9 mon among African American and Hispanic women 

10 and Hispanic men compared to non-Hispanic Cauca11 sians, independent of other factors including obesity. 

12 (8) African Americans with sleep-disordered 

13 breathing develop symptoms at a younger age than 

14 Caucasians but appear less likely to be diagnosed 

15 and treated in a timely manner. This delay may at 

16 least in part be due to reduced access to care. 

17 (9) Sleep loss contributes to increased risk for 

18 chronic conditions such as obesity, diabetes, and hy19 pertension, all of which have increased prevalence in 

20 underserved, underrepresented minorities. Racial 

21 and ethnic disparities related to obesity may also 

22 contribute to disparities in health outcomes related 

23 to sleep-disordered breathing. 


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1 (10) Non-Caucasian adults report an insomnia 

2 rate of 12.9 percent compared to only 6.6 percent 

3 for Caucasians. 

4 (11) African-American women have a higher in5 cidence of insomnia than African-American men, 

6 perhaps related in part to higher risk for chronic 

7 persisting symptoms. 

8 SEC. 792. SLEEP AND CIRCADIAN RHYTHM DISORDERS RE9 SEARCH ACTIVITIES OF THE NATIONAL IN10 STITUTES OF HEALTH. 

11 (a) IN GENERAL.—The Director of the National In12 stitutes of Health, acting through the Director of the Na13 tional Heart, Lung, and Blood Institute, shall— 

14 (1) continue to expand research activities ad15 dressing sleep health disparities; and 

16 (2) continue implementation of the ‘‘NIH Sleep 

17 Disorders Research Plan’’ across all institutes and 

18 centers of the National Institutes of Health to im19 prove treatment and prevention of sleep health dis20 parities. 

21 (b) REQUIRED RESEARCH ACTIVITIES.—In con22 ducting or supporting research relating to sleep and circa23 dian rhythm, the Director of the National Heart, Lung, 

24 and Blood Institute shall— 


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1 (1) advance epidemiology and clinical research 

2 to achieve a more complete understanding of dispari3 ties in domains of sleep health and across population 

4 subgroups for which cardiovascular and metabolic 

5 health disparities exist, including— 

6 (A) prevalence and severity of sleep apnea; 

7 (B) habitual sleep duration; 

8 (C) sleep timing and regularity; and 

9 (D) insomnia; 

10 (2) develop study designs and analytical ap11 proaches to explain and predict multilevel and life12 course determinants of sleep health and to elucidate 

13 the sleep-related causes of cardiovascular and meta14 bolic health disparities across the age spectrum, in15 cluding such determinants and causes that are— 

16 (A) environmental; 

17 (B) biological or genetic; 

18 (C) psychosocial; 

19 (D) societal; 

20 (E) political; or 

21 (F) economic; 

22 (3) determine the contribution of sleep impair23 ments such as sleep apnea, insufficient sleep dura24 tion, irregular sleep schedules, and insomnia to unVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00719 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 explained disparities in cardiovascular and metabolic 

2 risk and disease outcomes; 

3 (4) develop study designs, data sampling and 

4 collection tools, and analytical approaches to opti5 mize understanding of mediating and moderating 

6 factors, and feedback mechanisms coupling sleep to 

7 cardiovascular and metabolic health disparities; 

8 (5) advance research to understand cultural 

9 and linguistic barriers (on the person, provider, or 

10 system level) to access to care, medical diagnosis, 

11 and treatment of sleep disorders in diverse popu12 lation groups; 

13 (6) develop and test multilevel interventions (in14 cluding sleep health education in diverse commu15 nities) to reduce disparities in sleep health that will 

16 impact ability to improve disparities in cardio17 vascular and metabolic risk or disease; 

18 (7) create opportunities to integrate sleep and 

19 health disparity science by strategically utilizing re20 sources (existing or anticipated cohorts), exchanging 

21 scientific data and ideas (cross-over into scientific 

22 meetings), and develop multidisciplinary investi23 gator-initiated grant applications; and 


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1 (8) enhance the diversity and foster career de2 velopment of young investigators involved in sleep 

3 and health disparities science. 

4 (c) AUTHORIZATION OF APPROPRIATIONS.—To carry 

5 out this section, there are authorized to be appropriated 

6 such sums as may be necessary for fiscal year 2019 and 

7 each subsequent fiscal year. 

8 SEC. 793. SLEEP AND CIRCADIAN RHYTHM HEALTH DIS9 PARITIES-RELATED ACTIVITIES OF THE CEN10 TERS FOR DISEASE CONTROL AND PREVEN11 TION. 

12 (a) IN GENERAL.—The Director of the Centers for 

13 Disease Control and Prevention shall conduct, support, 

14 and expand public health strategies and prevention, diag15 nosis, surveillance, and public and professional awareness 

16 activities regarding sleep and circadian rhythm disorders. 

17 (b) FINDINGS.—The Congress finds as follows: 

18 (1) Sleep disorders and sleep deficiency unre19 lated to a primary sleep disorder are underdiagnosed 

20 and are increasingly detrimental to health status. 

21 (2) The consequences to society include addi22 tional diseases, motor vehicle accidents, decreased 

23 longevity, elevated direct medical costs, and indirect 

24 costs related to work absenteeism and property dam25 age. 


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1 (c) REQUIRED SURVEILLANCE AND EDUCATION

2 AWARENESS ACTIVITIES.—In conducting or supporting 

3 research relating to sleep and circadian rhythm disorders 

4 surveillance and education awareness activities, the Direc5 tor of the Centers for Disease Control and Prevention 

6 shall— 

7 (1) ensure that such activities are culturally 

8 and linguistically appropriate to minority patients, 

9 targeting sleep and circadian rhythm health pro10 motion and prevention programs of each major eth11 nic group, including— 

12 (A) Native Americans and Alaska Natives; 

13 (B) Asian Americans; 

14 (C) African Americans/Blacks; 

15 (D) Hispanic/Latino-Americans; and 

16 (E) Native Hawaiians and Pacific Island17 ers; 

18 (2) collect and compile national and State sur19 veillance data on sleep disorders health disparities; 

20 (3) continue to develop and implement new 

21 sleep questions in public health surveillance systems 

22 to increase public awareness of sleep health and 

23 sleep disorders and their impact on health; 

24 (4) publish monthly reports highlighting geo25 graphic, racial, and ethnic disparities in sleep health, 


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1 as well as relationships between insufficient sleep 

2 and chronic disease, health risk behaviors, and other 

3 outcomes as determined necessary by the Director; 

4 and 

5 (5) include public awareness campaigns that in6 form patient populations from major ethnic groups 

7 about the prevalence of sleep and circadian rhythm 

8 disorders and emphasize the importance of sleep 

9 health. 

10 (d) AUTHORIZATION OF APPROPRIATIONS.—To carry 

11 out this section, there are authorized to be appropriated 

12 such sums as may be necessary for fiscal year 2019 and 

13 each subsequent fiscal year. 

14 SEC. 794. GRANTS FOR COMPREHENSIVE SLEEP AND CIR15 CADIAN HEALTH EDUCATION WITHIN 

16 HEALTH PROFESSIONS SCHOOLS. 

17 (a) PROGRAM AUTHORIZED.—The Secretary of 

18 Health and Human Services (in this section referred to 

19 as the ‘‘Secretary’’), in coordination with the Secretary of 

20 Education, shall award grants, on a competitive basis, to 

21 academic health science centers, health professions 

22 schools, and other institutions of higher education to en23 able such institutions to provide people with comprehen24 sive education on sleep and circadian health, particu25 larly— 


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1 (1) poor sleep health; 

2 (2) sleep disorders; 

3 (3) sleep health disparities; and 

4 (4) the relationship between sleep and circadian 

5 health on metabolic activity, neurological activity, 

6 comorbidities, and other diseases. 

7 (b) DURATION.—Grants awarded under this section 

8 shall be for a period of 5 years. 

9 (c) APPLICATIONS.—Any academic health science 

10 center, health professions school, or other institutions of 

11 higher education seeking a grant under this section shall 

12 submit an application to the Secretary at such time, in 

13 such manner, and containing such information as the Sec14 retary may require. 

15 (d) PRIORITY.—In awarding grants under this sec16 tion, the Secretary shall give priority to an institution 

17 that— 

18 (1) has an enrollment of needy students, as de19 fined in section 318(b) of the Higher Education Act 

20 of 1965 (20 U.S.C. 1059e(b)); 

21 (2) is a Hispanic-serving institution, as defined 

22 in section 502(a) of such Act (20 U.S.C. 1101a(a)); 

23 (3) is a Tribal College or University, as defined 

24 in section 316(b) of such Act (20 U.S.C. 1059c(b)); 


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1 (4) is an Alaska Native-serving institution, as 

2 defined in section 317(b) of such Act (20 U.S.C. 

3 1059d(b)); 

4 (5) is a Native Hawaiian-serving institution, as 

5 defined in section 317(b) of such Act (20 U.S.C. 

6 1059d(b)); 

7 (6) is a Predominately Black Institution, as de8 fined in section 318(b) of such Act (20 U.S.C. 

9 1059e(b)); 

10 (7) is a Native American-serving, nontribal in11 stitution, as defined in section 319(b) of such Act 

12 (20 U.S.C. 1059f(b)); 

13 (8) is an Asian-American and Native American 

14 Pacific Islander-serving institution, as defined in 

15 section 320(b) of such Act (20 U.S.C. 1059g(b)); or 

16 (9) is a minority institution, as defined in sec17 tion 365 of such Act (20 U.S.C. 1067k), with an en18 rollment of needy students, as defined in section 312 

19 of such Act (20 U.S.C. 1058). 

20 (e) USES OF FUNDS.—An institution of higher edu21 cation receiving a grant under this section may use grant 

22 funds to integrate issues relating to comprehensive sleep 

23 and circadian health into the academic or support sectors 

24 of the institution in order to reach a large number of stu25 dents, by carrying out 1 or more of the following activities: 


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1 (1) Developing educational content for issues 

2 relating to comprehensive sleep and circadian health 

3 education that will be incorporated into first-year 

4 orientation or core courses. 

5 (2) Creating innovative technology-based ap6 proaches to deliver sleep health education to stu7 dents, faculty, and staff. 

8 (3) Developing and employing peer-outreach 

9 and education programs to generate discussion, edu10 cate, and raise awareness among students about 

11 issues relating to poor quality sleep, sleep and circa12 dian disorders, and the role sleep health plays in 

13 other diseases and comorbidities. 

14 (f) REPORT TO CONGRESS.— 

15 (1) IN GENERAL.—Not later than 1 year after 

16 the date of the enactment of this Act, and annually 

17 thereafter for a period of 5 years, the Secretary shall 

18 prepare and submit to the appropriate committees of 

19 Congress a report on the activities to provide health 

20 professions students with comprehensive sleep and 

21 circadian health education funded under this section. 

22 (2) REPORT ELEMENTS.—The report described 

23 in paragraph (1) shall include information about— 


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1 (A) the number of eligible entities and in2 stitutions of higher education that are receiving 

3 grant funds; 

4 (B) the specific activities supported by 

5 grant funds; 

6 (C) the number of students served by 

7 grant programs; and 

8 (D) the status of program evaluations. 

9 SEC. 795. REPORT ON IMPACT OF SLEEP AND CIRCADIAN 

10 HEALTH DISORDERS IN VULNERABLE AND 

11 RACIAL/ETHNIC POPULATIONS. 

12 (a) IN GENERAL.—Not later than 1 year after the 

13 date of enactment of this Act, the Secretary of Health and 

14 Human Services shall submit to the Congress and the 

15 President a report on the impact of sleep and circadian 

16 health disorders for racial and ethnic minority commu17 nities and other vulnerable populations. 

18 (b) CONTENTS.—The report under subsection (a) 

19 shall include information on the— 

20 (1) progress that has been made in reducing 

21 the impact of sleep and circadian health disorders in 

22 such communities and populations; 

23 (2) opportunities that exist to make additional 

24 progress in reducing the impact of sleep and circaVerDate Sep 11 2014 20:12 Jun 26, 2018 Jkt 079200 PO 00000 Frm 00727 Fmt 6652 Sfmt 6201 E:\BILLS\H5942.IH H5942

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1 dian health disorders in such communities and popu2 lations; 

3 (3) challenges that may impede such additional 

4 progress; and 

5 (4) Federal funding necessary to achieve sub6 stantial reductions in sleep and circadian health dis7 orders in racial and ethnic minority communities. 

8 Subtitle K—Sickle Cell Disease Re9 search, Surveillance, Preven10 tion, and Treatment 

11 SEC. 796. SHORT TITLE. 

12 This subtitle may be cited as the ‘‘Sickle Cell Disease 

13 Research, Surveillance, Prevention, and Treatment Act of 

14 2018’’. 

15 SEC. 796A. SICKLE CELL DISEASE RESEARCH. 

16 Part P of title III of the Public Health Service Act 

17 (42 U.S.C. 280g et seq.), as amended, is further amended 

18 by adding at the end the following: 

19 ‘‘SEC. 399V–11. NATIONAL SICKLE CELL DISEASE RE20 SEARCH, SURVEILLANCE, PREVENTION, AND 

21 TREATMENT PROGRAM. 

22 ‘‘(a) RESEARCH.—The Secretary may conduct or 

23 support research to expand the understanding of the cause 

24 of, and to find a cure for, sickle cell disease.’’. 


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1 SEC. 796B. SICKLE CELL DISEASE SURVEILLANCE. 

2 Section 399V–11 of the Public Health Service Act, 

3 as added by section 796A, is amended by adding at the 

4 end the following: 

5 ‘‘(b) SURVEILLANCE.— 

6 ‘‘(1) GRANTS.—The Secretary may, for each 

7 fiscal year for which appropriations are available to 

8 carry out this subsection, make grants— 

9 ‘‘(A) to conduct surveillance and maintain 

10 data on the prevalence and distribution of sickle 

11 cell disease and its associated health outcomes, 

12 complications, and treatments; 

13 ‘‘(B) to conduct public health initiatives 

14 with respect to sickle cell disease, including— 

15 ‘‘(i) increasing efforts to improve ac16 cess to, and receipt of, high-quality sickle 

17 cell disease-related health care, including 

18 the use of treatments approved under sec19 tion 505 of the Federal Food, Drug, and 

20 Cosmetic Act or licensed under section 351 

21 of this Act; 

22 ‘‘(ii) working with partners to improve 

23 health outcomes of people with sickle cell 

24 disease over their lifespan by promoting 

25 guidelines for sickle cell disease screening, 

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1 agement of sickle cell disease complica2 tions; 

3 ‘‘(iii) providing support to community4 based organizations and State and local 

5 health departments in conducting sickle 

6 cell disease education and training activi7 ties for patients, communities, and health 

8 care providers; and 

9 ‘‘(iv) supporting and training State 

10 health departments and regional labora11 tories in comprehensive testing to identify 

12 specific forms of sickle cell disease in peo13 ple of all ages; and 

14 ‘‘(C) to identify and evaluate promising 

15 strategies for prevention and treatment of sickle 

16 cell disease complications, including through— 

17 ‘‘(i) improving estimates of the na18 tional incidence and prevalence of sickle 

19 cell disease, including estimates about the 

20 specific types of sickle cell disease; 

21 ‘‘(ii) identifying health disparities re22 lated to sickle cell disease; 

23 ‘‘(iii) assessing the utilization of 

24 therapies and strategies to prevent com25 plications related to sickle cell disease; and 


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1 ‘‘(iv) evaluating the impact of genetic, 

2 environmental, behavioral, and other risk 

3 factors that may affect sickle cell disease 

4 health outcomes. 

5 ‘‘(2) POPULATION INCLUDED.—The Secretary 

6 shall, to the extent practicable, award grants under 

7 this subsection to States, academic institutions, or 

8 nonprofit organizations across the United States so 

9 as to include data on the majority of the United 

10 States population with sickle cell disease. 

11 ‘‘(3) APPLICATION.—To seek a grant under this 

12 subsection, a State, academic institution, or non13 profit organization shall submit an application to the 

14 Secretary at such time, in such manner, and con15 taining such information as the Secretary may re16 quire. 

17 ‘‘(4) DEFINITIONS.—In this subsection: 

18 ‘‘(A) SECRETARY.—The term ‘Secretary’ 

19 means the Secretary of Health and Human 

20 Services, acting through the Director of the Na21 tional Center on Birth Defects and Develop22 mental Disabilities. 

23 ‘‘(B) STATE.—The term ‘State’ includes 

24 the 50 States, the District of Columbia, the 

25 Commonwealth of Puerto Rico, the United 


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1 States Virgin Islands, the Commonwealth of the 

2 Northern Mariana Islands, American Samoa, 

3 Guam, the Federated States of Micronesia, the 

4 Republic of the Marshall Islands, and the Re5 public of Palau.’’. 

6 SEC. 796C. SICKLE CELL DISEASE PREVENTION AND 

7 TREATMENT. 

8 (a) REAUTHORIZATION.—Section 712(c) of the 

9 American Jobs Creation Act of 2004 (Public Law 108– 

10 357; 42 U.S.C. 300b–1 note) is amended— 

11 (1) by striking ‘‘Sickle Cell Disease’’ each place 

12 it appears and inserting ‘‘sickle cell disease’’; 

13 (2) in paragraph (1)(A), by striking ‘‘grants to 

14 up to 40 eligible entities for each fiscal year in which 

15 the program is conducted under this section for the 

16 purpose of developing and establishing systemic 

17 mechanisms to improve the prevention and treat18 ment of Sickle Cell Disease’’ and inserting ‘‘grants 

19 to up to 25 eligible entities for each fiscal year in 

20 which the program is conducted under this section 

21 for the purpose of developing and establishing sys22 temic mechanisms to improve the prevention and 

23 treatment of sickle cell disease in populations with 

24 a high density of sickle cell disease patients’’; 

25 (3) in paragraph (1)(B)— 


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1 (A) by striking clause (ii) (relating to pri2 ority); and 

3 (B) by striking ‘‘GRANT AWARD REQUIRE4 MENTS’’ and all that follows through ‘‘the ad5 ministrator shall’’ and inserting ‘‘GEOGRAPHIC

6 DIVERSITY.—The Administrator shall’’; 

7 (4) in paragraph (2), by adding the following 

8 new subparagraph at the end: 

9 ‘‘(E) To expand, coordinate, and imple10 ment transition services for adolescents with 

11 sickle cell disease making the transition to adult 

12 health care.’’; and 

13 (5) in paragraph (6), by striking ‘‘$10,000,000 

14 for each of fiscal years 2005 through 2009’’ and in15 serting ‘‘$4,455,000 for each of fiscal years 2019 

16 through 2023’’. 

17 (b) TECHNICAL CHANGES.—Subsection (c) of section 

18 712 of the American Jobs Creation Act of 2004 (Public 

19 Law 108–357; 42 U.S.C. 300b–1 note), as amended by 

20 subsection (a), is— 

21 (1) transferred to the Public Health Service Act 

22 (42 U.S.C. 201 et seq.); and 

23 (2) inserted at the end of section 399V–11 of 

24 such Act, as added and amended by sections 796A 

25 and 796B. 


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1 SEC. 796D. COLLABORATION WITH COMMUNITY-BASED EN2 TITIES. 

3 Section 399V–11 of the Public Health Service Act, 

4 as amended by section 796C, is further amended by add5 ing at the end the following: 

6 ‘‘(d) COLLABORATION WITH COMMUNITY-BASED EN7 TITIES.—To be eligible to receive a grant or other assist8 ance under subsection (b) or (c), an entity must have in 

9 effect a collaborative agreement with a community-based 

10 organization with 5 or more years of experience in pro11 viding services to sickle cell disease patients.’’. 

12 TITLE VIII—HEALTH 

13 INFORMATION TECHNOLOGY 

14 SEC. 800. DEFINITIONS. 

15 In this title: 

16 (1) CERTIFIED ELECTRONIC HEALTH RECORD

17 TECHNOLOGY.—The term ‘‘Certified Electronic 

18 Health Record Technology’’ has the meaning given 

19 to that term in section 3000 of the Public Health 

20 Service Act (42 U.S.C. 300jj). 

21 (2) EHR.—The term ‘‘EHR’’ means an elec22 tronic health record. 


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1 Subtitle A—Reducing Health 

2 Disparities Through Health IT 

3 SEC. 801. HRSA ASSISTANCE TO HEALTH CENTERS FOR 

4 PROMOTION OF HEALTH IT. 

5 The Secretary of Health and Human Services, acting 

6 through the Administrator of the Health Resources and 

7 Services Administration, shall expand and intensify the 

8 programs and activities of the Administration (directly or 

9 through grants or contracts) to provide technical assist10 ance and resources to health centers (as defined in section 

11 330(a) of the Public Health Service Act (42 U.S.C. 

12 254b(a)) to adopt and meaningfully use Certified Elec13 tronic Health Record Technology for the management of 

14 chronic diseases and health conditions and reduction of 

15 health disparities. 

16 SEC. 802. ASSESSMENT OF IMPACT OF HEALTH IT ON RA17 CIAL AND ETHNIC MINORITY COMMUNITIES; 

18 OUTREACH AND ADOPTION OF HEALTH IT IN 

19 SUCH COMMUNITIES. 

20 (a) NATIONAL COORDINATOR FOR HEALTH INFOR21 MATION TECHNOLOGY.— 

22 (1) IN GENERAL.—The National Coordinator 

23 for Health Information Technology shall conduct an 

24 evaluation of the level of use and accessibility of 

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1 ity communities focusing on whether patients in 

2 those communities have providers with electronic 

3 health records, stratified by providers participating 

4 in Medicare and Medicaid programs, and whether 

5 such providers have received EHR incentive pay6 ments under the HITECH Act, and by providers 

7 participating in the Merit-Based Incentive Payment 

8 System (MIPS) under the Quality Payment Pro9 gram (QPP) established by the Medicare Access and 

10 CHIP Reauthorization Act of 2015 (MACRA). 

11 (2) CONTENT.—In conducting the evaluation 

12 under paragraph (1), the National Coordinator shall 

13 publish the results of a study regarding the 100,000 

14 providers recruited by the Regional Extension Cen15 ter established under section 3012 of the Public 

16 Health Service Act (42 U.S.C. 300jj–32), including 

17 the race and ethnicity of such providers and the pop18 ulations served by such providers, with the popu19 lations stratified by providers participating in Medi20 care and Medicaid programs, and whether such pro21 viders have received EHR incentive payments under 

22 the HITECH Act, and by providers participating in 

23 the MIPS. 

24 (b) NATIONAL CENTER FOR HEALTH STATISTICS.— 

25 As soon as practicable after the date of enactment of this 


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1 Act, the Director of the National Center for Health Statis2 tics shall provide to Congress a more detailed analysis of 

3 the data presented in NCHS Data Brief No. 236, Adop4 tion of Certified Electronic Health Record Systems and 

5 Electronic Information Sharing in Physician Offices: 

6 United States, 2013 and 2014 the Data Brief 79. 

7 (c) CENTERS FOR MEDICARE & MEDICAID SERV8 ICES.— 

9 (1) IN GENERAL.—As part of the process of 

10 collecting information, with respect to a provider, at 

11 registration and attestation for purposes of the 

12 Medicare and Medicaid Electronic Health Records 

13 Incentive Programs and MIPS, the Secretary of 

14 Health and Human Services shall collect the race 

15 and ethnicity of such provider. 

16 (2) MEDICARE AND MEDICAID ELECTRONIC

17 HEALTH RECORDS INCENTIVE PROGRAMS DE18 FINED.—For purposes of paragraph (1), the term 

19 ‘‘Medicare and Medicaid Electronic Health Records 

20 Incentive Programs’’ means the incentive programs 

21 under section 1814(l)(3), subsections (a)(7) and (o) 

22 of section 1848, subsections (l) and (m) of section 

23 1853, subsections (b)(3)(B)(ix)(I) and (n) of section 

24 1886, and subsections (a)(3)(F) and (t) of section 

25 1903 of the Social Security Act (42 U.S.C. 


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1 1395f(l)(3), 1395w–4, 1395w–23, 1395ww, and 

2 1396b). 

3 (d) NATIONAL COORDINATOR’S ASSESSMENT OF IM4 PACT OF HIT.—Section 3001(c)(6)(C) of the Public 

5 Health Service Act (42 U.S.C. 300jj–11(c)(6)(C)) is 

6 amended— 

7 (1) in the heading by inserting ‘‘, RACIAL AND

8 ETHNIC MINORITY COMMUNITIES,’’ after ‘‘HEALTH

9 DISPARITIES’’; 

10 (2) by inserting ‘‘, in communities with a high 

11 proportion of individuals from racial and ethnic mi12 nority groups (as defined in section 1707(g)), in13 cluding people with disabilities in these groups,’’ 

14 after ‘‘communities with health disparities’’; and 

15 (3) by adding at the end the following new sen16 tence: ‘‘In any publication under the previous sen17 tence, the National Coordinator shall include best 

18 practices for encouraging partnerships between the 

19 Federal Government, States, and private entities to 

20 expand outreach for and the adoption of certified 

21 EHR technology in communities with a high propor22 tion of individuals from racial and ethnic minority 

23 groups (as so defined), while also maintaining the 

24 accessibility requirements of section 508 of the Re25 habilitation Act to encourage patient involvement in 


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1 patient health care. The National Coordinator 

2 shall— 

3 ‘‘(i) not later than 6 months after the 

4 submission to the Congress of the report 

5 required by section 822 of the Health Eq6 uity and Accountability Act of 2018, estab7 lish criteria for evaluating the impact of 

8 health information technology on commu9 nities with a high proportion of individuals 

10 from racial and ethnic minority groups (as 

11 so defined) taking into account the find12 ings in such report; and 

13 ‘‘(ii) not later than 12 months after 

14 the submission to the Congress of such re15 ports, conduct and publish the results of 

16 an evaluation of such impact.’’. 

17 Subtitle B—Modifications To 

18 Achieve Parity in Existing Pro19 grams 

20 SEC. 811. EXTENDING FUNDING TO STRENGTHEN THE 

21 HEALTH IT INFRASTRUCTURE IN RACIAL 

22 AND ETHNIC MINORITY COMMUNITIES. 

23 Section 3011 of the Public Health Service Act (42 

24 U.S.C. 300jj–31) is amended— 


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1 (1) in subsection (a), by adding at the end the 

2 following new paragraph: 

3 ‘‘(8) Activities described in the previous para4 graphs of this subsection with respect to commu5 nities with a high proportion of individuals from ra6 cial and ethnic minority groups (as defined in sec7 tion 1707(g)).’’; and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(e) ANNUAL REPORT ON EXPENDITURES.—The 

11 National Coordinator shall report annually to the Con12 gress on activities and expenditures under this section.’’. 

13 SEC. 812. EXTENDING COMPETITIVE GRANTS FOR THE DE14 VELOPMENT OF LOAN PROGRAMS TO FACILI15 TATE ADOPTION OF CERTIFIED ELECTRONIC 

16 HEALTH RECORD TECHNOLOGY BY PRO17 VIDERS SERVING RACIAL AND ETHNIC MI18 NORITY GROUPS. 

19 Section 3014(e) of the Public Health Service Act (42 

20 U.S.C. 300jj–34(e)) is amended— 

21 (1) in paragraph (3), by striking at the end 

22 ‘‘or’’; 

23 (2) in paragraph (4), by striking the period at 

24 the end and inserting ‘‘; or’’; and 


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1 (3) by adding at the end the following new 

2 paragraph: 

3 ‘‘(5) carry out any of the activities described in 

4 a previous paragraph of this subsection with respect 

5 to communities with a high proportion of individuals 

6 from racial and ethnic minority groups (as defined 

7 in section 1707(g)).’’. 

8 SEC. 813. AUTHORIZATION OF APPROPRIATIONS. 

9 Section 3018 of the Public Health Service Act (42 

10 U.S.C. 300jj–38) is amended by striking ‘‘fiscal years 

11 2009 through 2013’’ and inserting ‘‘fiscal years 2019 

12 through 2024’’. 

13 Subtitle C—Additional Research 

14 and Studies 

15 SEC. 821. DATA COLLECTION AND ASSESSMENTS CON16 DUCTED IN COORDINATION WITH MINORITY17 SERVING INSTITUTIONS. 

18 Section 3001(c)(6) of the Public Health Service Act 

19 (42 U.S.C. 300jj–11(c)(6)) is amended by adding at the 

20 end the following new subparagraph: 

21 ‘‘(F) DATA COLLECTION AND ASSESS22 MENTS CONDUCTED IN COORDINATION WITH

23 MINORITY-SERVING INSTITUTIONS.— 

24 ‘‘(i) IN GENERAL.—In carrying out 

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1 nities with a high proportion of individuals 

2 from racial and ethnic minority groups (as 

3 defined in section 1707(g)), the National 

4 Coordinator shall, to the greatest extent 

5 possible, coordinate with an entity de6 scribed in clause (ii). 

7 ‘‘(ii) MINORITY-SERVING INSTITU8 TIONS.—For purposes of clause (i), an en9 tity described in this clause is a historically 

10 Black college or university, a Hispanic11 serving institution, a Tribal college or uni12 versity, or an Asian-American-, Native 

13 American-, Pacific Islander-serving institu14 tion with an accredited public health, 

15 health policy, or health services research 

16 program.’’. 

17 SEC. 822. STUDY OF HEALTH INFORMATION TECHNOLOGY 

18 IN MEDICALLY UNDERSERVED COMMU19 NITIES. 

20 (a) IN GENERAL.—Not later than 24 months after 

21 the date of enactment of this Act, the Secretary of Health 

22 and Human Services shall— 

23 (1) enter into an agreement with the National 

24 Academies of Sciences, Engineering, and Medicine to 

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1 tion, and effectiveness of health information tech2 nology within medically underserved areas (as de3 scribed in subsection (c)); and 

4 (2) submit a report to Congress describing the 

5 results of such study, including any recommenda6 tions for legislative or administrative action. 

7 (b) STUDY.—The study described in subsection 

8 (a)(1) shall— 

9 (1) identify barriers to successful implementa10 tion of health information technology in medically 

11 underserved areas; 

12 (2) examine the impact of health information 

13 technology on providing quality care and reducing 

14 the cost of care to individuals in such areas, includ15 ing the impact of such technology on improved 

16 health outcomes for individuals, including which 

17 technology worked for which population and how it 

18 improved health outcomes for that population; 

19 (3) examine the impact of health information 

20 technology on improving health care-related deci21 sions by both patients and providers in such areas; 

22 (4) identify specific best practices for using 

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1 able policy accommodations in health care to individ2 uals with disabilities in such areas; 

3 (5) assess the feasibility and costs associated 

4 with the use of health information technology in 

5 such areas; 

6 (6) evaluate whether the adoption and use of 

7 qualified electronic health records (as described in 

8 section 3000(13) of the Public Health Service Act 

9 (42 U.S.C. 300jj(13)) is effective in reducing health 

10 disparities, including analysis of clinical quality 

11 measures reported by Medicare and Medicaid pro12 viders pursuant to programs to encourage the adop13 tion and use of Certified Electronic Health Record 

14 Technology; 

15 (7) identify providers in medically underserved 

16 areas that are not electing to adopt and use elec17 tronic health records and determine what barriers 

18 are preventing those providers from adopting and 

19 using such records; and 

20 (8) examine urban and rural community health 

21 systems and determine the impact that health infor22 mation technology may have on the capacity of pri23 mary health providers in those systems. 

24 (c) MEDICALLY UNDERSERVED AREA.—The term 

25 ‘‘medically underserved area’’ means— 


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1 (1) a population that has been designated as a 

2 medically underserved population under section 

3 330(b)(3) of the Public Health Service Act (42 

4 U.S.C. 254b(b)(3)); 

5 (2) an area that has been designated as a 

6 health professional shortage area under section 332 

7 of the Public Health Service Act (42 U.S.C. 254e); 

8 (3) an area or population that has been des9 ignated as a medically underserved community under 

10 section 799B(6) of the Public Health Service Act 

11 (42 U.S.C. 295p(6)); or 

12 (4) an area or population that— 

13 (A) is not described in paragraphs (1) 

14 through (3) of this subsection; 

15 (B) experiences significant barriers to ac16 cessing quality health services; and 

17 (C) has a high prevalence of diseases or 

18 conditions described in title VII of this Act, 

19 with such diseases or conditions having a dis20 proportionate impact on racial and ethnic mi21 nority groups (as defined in section 1707(g) of 

22 the Public Health Service Act (42 U.S.C. 

23 300u–6(g))) or a subgroup of people with dis24 abilities who have specific functional impair25 ments. 


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1 Subtitle D—Closing Gaps in 

2 Funding To Adopt Certified EHRs 

3 SEC. 831. EXTENDING MEDICAID EHR INCENTIVE PAY4 MENTS TO REHABILITATION FACILITIES, 

5 LONG-TERM CARE FACILITIES, AND HOME 

6 HEALTH AGENCIES. 

7 Section 1903(t)(2)(B) of the Social Security Act (42 

8 U.S.C. 1396b(t)(2)(B)) is amended— 

9 (1) in clause (i), by striking ‘‘, or’’ and insert10 ing a semicolon; 

11 (2) in clause (ii), by striking the period at the 

12 end and inserting a semicolon; and 

13 (3) by inserting after clause (ii) the following 

14 new clauses: 

15 ‘‘(iii) a rehabilitation facility (as defined in sec16 tion 1886(j)(1)) that furnishes acute or subacute re17 habilitation services; 

18 ‘‘(iv) a long-term care hospital (as defined in 

19 section 1886(d)(1)(B)(iv)(I)); or 

20 ‘‘(v) a home health agency (as defined in sec21 tion 1861(o)).’’. 


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1 SEC. 832. EXTENDING PHYSICIAN ASSISTANT ELIGIBILITY 

2 FOR MEDICAID ELECTRONIC HEALTH 

3 RECORD INCENTIVE PAYMENTS. 

4 (a) IN GENERAL.—Section 1903(t)(3)(B)(v) of the 

5 Social Security Act (42 U.S.C. 1396b(t)(3)(B)(v)) is 

6 amended to read as follows: 

7 ‘‘(v) physician assistant.’’. 

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

9 subsection (a) shall apply with respect to amounts ex10 pended under section 1903(a)(3)(F) of the Social Security 

11 Act (42 U.S.C. 1396b(a)(3)(F)) for calendar quarters be12 ginning on or after the date of the enactment of this Act. 

13 TITLE IX—ACCOUNTABILITY 

14 AND EVALUATION 

15 SEC. 901. PROHIBITION ON DISCRIMINATION IN FEDERAL 

16 ASSISTED HEALTH CARE SERVICES AND RE17 SEARCH PROGRAMS ON THE BASIS OF SEX, 

18 RACE, COLOR, NATIONAL ORIGIN, MARITAL 

19 STATUS, FAMILIAL STATUS, SEXUAL ORI20 ENTATION, GENDER IDENTITY, OR DIS21 ABILITY STATUS. 

22 (a) IN GENERAL.—No person in the United States 

23 shall, on the basis of sex, race, color, national origin, mar24 ital status, familial status, sexual orientation, gender iden25 tity, or disability status, be excluded from participation 

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1 tion under any health program or activity, including any 

2 health research program or activity, receiving Federal fi3 nancial assistance. 

4 (b) DEFINITION.—In this section, the term ‘‘familial 

5 status’’ means, with respect to one or more individuals— 

6 (1) being domiciled with any individual related 

7 by blood or affinity whose close association with the 

8 individual is the equivalent of a family relationship; 

9 (2) being in the process of securing legal cus10 tody of any individual; or 

11 (3) being pregnant. 

12 SEC. 902. TREATMENT OF MEDICARE PAYMENTS UNDER 

13 TITLE VI OF THE CIVIL RIGHTS ACT OF 1964. 

14 A payment to a provider of services, physician, or 

15 other supplier under part B, C, or D of title XVIII of 

16 the Social Security Act shall be deemed a grant, and not 

17 a contract of insurance or guaranty, for the purposes of 

18 title VI of the Civil Rights Act of 1964. 

19 SEC. 903. ACCOUNTABILITY AND TRANSPARENCY WITHIN 

20 THE DEPARTMENT OF HEALTH AND HUMAN 

21 SERVICES. 

22 Title XXXIV of the Public Health Service Act, as 

23 amended by titles I, II, and III of this Act, is further 

24 amended by inserting after subtitle B the following: 


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1 ‘‘Subtitle C—Strengthening 

2 Accountability 

3 ‘‘SEC. 3441. ELEVATION OF THE OFFICE OF CIVIL RIGHTS. 

4 ‘‘(a) IN GENERAL.—The Secretary shall establish 

5 within the Office for Civil Rights an Office of Health Dis6 parities, which shall be headed by a director to be ap7 pointed by the Secretary. 

8 ‘‘(b) PURPOSE.—The Office of Health Disparities 

9 shall ensure that the health programs, activities, and oper10 ations of health entities which receive Federal financial as11 sistance are in compliance with title VI of the Civil Rights 

12 Act, which prohibits discrimination on the basis of race, 

13 color, or national origin. The activities of the Office shall 

14 include the following: 

15 ‘‘(1) The development and implementation of 

16 an action plan to address racial and ethnic health 

17 care disparities, which shall address concerns relat18 ing to the Office for Civil Rights as released by the 

19 United States Commission on Civil Rights in the re20 port entitled ‘Health Care Challenge: Acknowledging 

21 Disparity, Confronting Discrimination, and Ensur22 ing Equity’ (September 1999) in conjunction with 

23 the reports by the Institute of Medicine entitled ‘Un24 equal Treatment: Confronting Racial and Ethnic 

25 Disparities in Health Care’, ‘Crossing the Quality 


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1 Chasm: A New Health System for the 21st Cen2 tury’, ‘In the Nation’s Compelling Interest: Ensur3 ing Diversity in the Health Care Workforce’, ‘The 

4 National Partnership for Action to End Health Dis5 parities’, and ‘The Health of Lesbian, Gay, Bisexual, 

6 and Transgender People’, and other related reports 

7 by the Institute of Medicine. This plan shall be pub8 licly disclosed for review and comment and the final 

9 plan shall address any comments or concerns that 

10 are received by the Office. 

11 ‘‘(2) Investigative and enforcement actions 

12 against intentional discrimination and policies and 

13 practices that have a disparate impact on minorities. 

14 ‘‘(3) The review of racial, ethnic, gender iden15 tity, sexual orientation, sex, disability status, socio16 economic status, and primary language health data 

17 collected by Federal health agencies to assess health 

18 care disparities related to intentional discrimination 

19 and policies and practices that have a disparate im20 pact on minorities. 

21 ‘‘(4) Outreach and education activities relating 

22 to compliance with title VI of the Civil Rights Act. 

23 ‘‘(5) The provision of technical assistance for 

24 health entities to facilitate compliance with title VI 

25 of the Civil Rights Act. 


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1 ‘‘(6) Coordination and oversight of activities of 

2 the civil rights compliance offices established under 

3 section 3442. 

4 ‘‘(7) Ensuring— 

5 ‘‘(A) at a minimum, compliance with the 

6 1997 Office of Management and Budget Stand7 ards for Maintaining, Collecting, and Pre8 senting Federal Data on Race and Ethnicity; 

9 and 

10 ‘‘(B) consideration of available data and 

11 language standards such as— 

12 ‘‘(i) the standards for collecting and 

13 reporting data under section 3101; and 

14 ‘‘(ii) the National Standards on Cul15 turally and Linguistically Appropriate 

16 Services of the Office of Minority Health 

17 within the Department of Health and 

18 Human Services. 

19 ‘‘(c) FUNDING AND STAFF.—The Secretary shall en20 sure the effectiveness of the Office of Health Disparities 

21 by ensuring that the Office is provided with— 

22 ‘‘(1) adequate funding to enable the Office to 

23 carry out its duties under this section; and 

24 ‘‘(2) staff with expertise in— 

25 ‘‘(A) epidemiology; 


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1 ‘‘(B) statistics; 

2 ‘‘(C) health quality assurance; 

3 ‘‘(D) minority health and health dispari4 ties; 

5 ‘‘(E) cultural and linguistic competency; 

6 ‘‘(F) civil rights; and 

7 ‘‘(G) social, behavioral, and economic de8 terminants of health. 

9 ‘‘(d) REPORT.—Not later than December 31, 2019, 

10 and annually thereafter, the Secretary, in collaboration 

11 with the Director of the Office for Civil Rights and the 

12 Deputy Assistant Secretary for Minority Health, shall 

13 submit a report to the Committee on Health, Education, 

14 Labor, and Pensions of the Senate and the Committee on 

15 Energy and Commerce of the House of Representatives 

16 that includes— 

17 ‘‘(1) the number of cases filed, broken down by 

18 category; 

19 ‘‘(2) the number of cases investigated and 

20 closed by the office; 

21 ‘‘(3) the outcomes of cases investigated; 

22 ‘‘(4) the staffing levels of the office including 

23 staff credentials; 


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1 ‘‘(5) the number of other lingering and emerg2 ing cases in which civil rights inequities can be dem3 onstrated; and 

4 ‘‘(6) the number of cases remaining open and 

5 an explanation for their open status. 

6 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There 

7 are authorized to be appropriated to carry out this section 

8 such sums as may be necessary for each of fiscal years 

9 2019 through 2024. 

10 ‘‘SEC. 3442. ESTABLISHMENT OF HEALTH PROGRAM OF11 FICES FOR CIVIL RIGHTS WITHIN FEDERAL 

12 HEALTH AND HUMAN SERVICES AGENCIES. 

13 ‘‘(a) IN GENERAL.—The Secretary shall establish 

14 civil rights compliance offices in each agency within the 

15 Department of Health and Human Services that admin16 isters health programs. 

17 ‘‘(b) PURPOSE OF OFFICES.—Each office established 

18 under subsection (a) shall ensure that recipients of Fed19 eral financial assistance under Federal health programs 

20 administer their programs, services, and activities in a 

21 manner that— 

22 ‘‘(1) does not discriminate, either intentionally 

23 or in effect, on the basis of race, national origin, lan24 guage, ethnicity, sex, age, disability, sexual orienta25 tion, and gender identity; and 


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1 ‘‘(2) promotes the reduction and elimination of 

2 disparities in health and health care based on race, 

3 national origin, language, ethnicity, sex, age, dis4 ability, sexual orientation, and gender identity. 

5 ‘‘(c) POWERS AND DUTIES.—The offices established 

6 in subsection (a) shall have the following powers and du7 ties: 

8 ‘‘(1) The establishment of compliance and pro9 gram participation standards for recipients of Fed10 eral financial assistance under each program admin11 istered by an agency within the Department of 

12 Health and Human Services including the establish13 ment of disparity reduction standards to encompass 

14 disparities in health and health care related to race, 

15 national origin, language, ethnicity, sex, age, dis16 ability, sexual orientation, and gender identity. 

17 ‘‘(2) The development and implementation of 

18 program-specific guidelines that interpret and apply 

19 Department of Health and Human Services guid20 ance under title VI of the Civil Rights Act of 1964 

21 and section 1557 of the Patient Protection and Af22 fordable Care Act to each Federal health program 

23 administered by the agency. 

24 ‘‘(3) The development of a disparity-reduction 

25 impact analysis methodology that shall be applied to 


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1 every rule issued by the agency and published as 

2 part of the formal rulemaking process under sections 

3 555, 556, and 557 of title 5, United States Code. 

4 ‘‘(4) Oversight of data collection, analysis, and 

5 publication requirements for all recipients of Federal 

6 financial assistance under each Federal health pro7 gram administered by the agency; compliance with, 

8 at a minimum, the 1997 Office of Management and 

9 Budget Standards for Maintaining, Collecting, and 

10 Presenting Federal Data on Race and Ethnicity; and 

11 consideration of available data and language stand12 ards such as— 

13 ‘‘(A) the standards for collecting and re14 porting data under section 3101; and 

15 ‘‘(B) the National Standards on Culturally 

16 and Linguistically Appropriate Services of the 

17 Office of Minority Health within the Depart18 ment of Health and Human Services. 

19 ‘‘(5) The conduct of publicly available studies 

20 regarding discrimination within Federal health pro21 grams administered by the agency as well as dis22 parity reduction initiatives by recipients of Federal 

23 financial assistance under Federal health programs. 

24 ‘‘(6) Annual reports to the Committee on 

25 Health, Education, Labor, and Pensions and the 


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1 Committee on Finance of the Senate and the Com2 mittee on Energy and Commerce and the Committee 

3 on Ways and Means of the House of Representatives 

4 on the progress in reducing disparities in health and 

5 health care through the Federal programs adminis6 tered by the agency. 

7 ‘‘(d) RELATIONSHIP TO OFFICE FOR CIVIL RIGHTS

8 IN THE DEPARTMENT OF JUSTICE.— 

9 ‘‘(1) DEPARTMENT OF HEALTH AND HUMAN

10 SERVICES.—The Office for Civil Rights in the De11 partment of Health and Human Services shall pro12 vide standard-setting and compliance review inves13 tigation support services to the Civil Rights Compli14 ance Office for each agency. 

15 ‘‘(2) DEPARTMENT OF JUSTICE.—The Office 

16 for Civil Rights in the Department of Justice shall 

17 continue to maintain the power to institute formal 

18 proceedings when an agency Office for Civil Rights 

19 determines that a recipient of Federal financial as20 sistance is not in compliance with the disparity re21 duction standards of the agency. 

22 ‘‘(e) DEFINITION.—In this section, the term ‘Federal 

23 health programs’ mean programs— 


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1 ‘‘(1) under the Social Security Act (42 U.S.C. 

2 301 et seq.) that pay for health care and services; 

3 and 

4 ‘‘(2) under this Act that provide Federal finan5 cial assistance for health care, biomedical research, 

6 health services research, and programs designed to 

7 improve the public’s health, including health service 

8 programs.’’. 

9 SEC. 904. UNITED STATES COMMISSION ON CIVIL RIGHTS. 

10 (a) COORDINATION WITHIN DEPARTMENT OF JUS11 TICE OF ACTIVITIES REGARDING HEALTH DISPARI12 TIES.—Section 3(a) of the Civil Rights Commission Act 

13 of 1983 (42 U.S.C. 1975a(a)) is amended— 

14 (1) in paragraph (1), by striking ‘‘and’’ at the 

15 end; 

16 (2) in paragraph (2), by striking the period at 

17 the end and inserting ‘‘; and’’; and 

18 (3) by adding at the end the following: 

19 ‘‘(3) shall, with respect to activities carried out 

20 in health care and correctional facilities toward the 

21 goal of eliminating health disparities between the 

22 general population and members of racial or ethnic 

23 minority groups, coordinate such activities of— 

24 ‘‘(A) the Office for Civil Rights within the 

25 Department of Justice; 


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1 ‘‘(B) the Office of Justice Programs within 

2 the Department of Justice; 

3 ‘‘(C) the Office for Civil Rights within the 

4 Department of Health and Human Services; 

5 and 

6 ‘‘(D) the Office of Minority Health within 

7 the Department of Health and Human Services 

8 (headed by the Deputy Assistant Secretary for 

9 Minority Health).’’. 

10 (b) AUTHORIZATION OF APPROPRIATIONS.—Section 

11 5 of the Civil Rights Commission Act of 1983 (42 U.S.C. 

12 1975c) is amended by striking the first sentence and in13 serting the following: ‘‘For the purpose of carrying out 

14 this Act, there are authorized to be appropriated 

15 $30,000,000 for fiscal year 2019, and such sums as may 

16 be necessary for each of the fiscal years 2020 through 

17 2024.’’. 

18 SEC. 905. SENSE OF CONGRESS CONCERNING FULL FUND19 ING OF ACTIVITIES TO ELIMINATE RACIAL 

20 AND ETHNIC HEALTH DISPARITIES. 

21 (a) FINDINGS.—Congress makes the following find22 ings: 

23 (1) The health status of the American populace 

24 is declining and the United States currently ranks 


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1 below most industrialized nations in health status 

2 measured by longevity, sickness, and mortality. 

3 (2) Racial and ethnic minority populations tend 

4 have the poorest health status and face substantial 

5 cultural, social, and economic barriers to obtaining 

6 quality health care. 

7 (3) Lesbian, gay, bisexual, transgender, queer, 

8 and questioning (LGBTQ) populations experience 

9 significant personal and structural barriers to ob10 taining high-quality health care. 

11 (4) Efforts to improve minority health have 

12 been limited by inadequate resources (funding, staff13 ing, and stewardship) and lack of accountability. 

14 (b) SENSE OF CONGRESS.—It is the sense of Con15 gress that— 

16 (1) health disparities negatively impact out17 comes for health and human security of the Nation; 

18 (2) reducing racial, ethnic, sexual, and gender 

19 disparities in prevention and treatment are unique 

20 civil and human rights challenges and as such Fed21 eral agencies and health care entities and systems 

22 receiving Federal funds must be accountable for 

23 their role in causing disparities and inequity; 

24 (3) funding should be doubled by fiscal year 

25 2020 for the National Institute for Minority Health 


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1 Disparities, the Office of Civil Rights in the Depart2 ment of Health and Human Services, the National 

3 Institute of Nursing Research, and the Office of Mi4 nority Health; 

5 (4) adequate funding by fiscal year 2020, and 

6 subsequent funding increases, should be provided for 

7 health and human service professions training pro8 grams, the Racial and Ethnic Approaches to Com9 munity Health (REACH) Initiative at the Centers 

10 for Disease Control and Prevention, the Minority 

11 HIV/AIDS Initiative, and the Excellence Centers to 

12 Eliminate Ethnic/Racial Disparities (EXCEED) 

13 Program at the Agency for Healthcare Research and 

14 Quality; 

15 (5) funding should be fully restored to the Ra16 cial and Ethnic Approaches to Community Health 

17 (REACH) Initiative at the Centers for Disease Con18 trol and Prevention, which has been a successful 

19 program at the community health level, and efforts 

20 should continue to place a strong emphasis on build21 ing community capacity to secure financial resources 

22 and technical assistance to eliminate health dispari23 ties; 

24 (6) adequate funding for fiscal year 2020 and 

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1 vided for the REACH Initiative’s United States Risk 

2 Factor Survey to ensure adequate data collection to 

3 track health disparities, and there should be appro4 priate avenues provided to disseminate findings to 

5 the general public; 

6 (7) current and newly created health disparity 

7 elimination incentives, programs, agencies, and de8 partments under this Act (and the amendments 

9 made by this Act) should receive adequate staffing 

10 and funding by fiscal year 2020; and 

11 (8) stewardship and accountability should be 

12 provided to the Congress and the President for 

13 measurable and sustainable progress toward health 

14 disparity elimination. 

15 SEC. 906. GAO AND NIH REPORTS. 

16 (a) GAO REPORT ON NIH GRANT RACIAL AND ETH17 NIC DIVERSITY.— 

18 (1) IN GENERAL.—The Comptroller General of 

19 the United States shall conduct a study on the racial 

20 and ethnic diversity among the following groups: 

21 (A) All applicants for grants, contracts, 

22 and cooperative agreements awarded by the Na23 tional Institutes of Health during the period be24 ginning on January 1, 2006, and ending De25 cember 31, 2017. 


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1 (B) All recipients of such grants, con2 tracts, and cooperative agreements. 

3 (C) All members of the peer review panels 

4 of such applicants and recipients, respectively. 

5 (2) REPORT.—Not later than six months after 

6 the date of the enactment of this Act, the Comp7 troller General shall complete the study under para8 graph (1) and submit to Congress a report con9 taining the results of such study. 

10 (b) NIH REPORT ON CERTAIN AUTHORITY OF NA11 TIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH

12 DISPARITIES.—Not later than six months after the date 

13 of the enactment of this Act, and biennially thereafter, the 

14 Director of the National Institutes of Health, in collabora15 tion with the Director of the National Institute on Minor16 ity Health and Health Disparities, shall submit to Con17 gress a report that details and evaluates— 

18 (1) the steps taken during the applicable report 

19 period by the Director of the National Institutes of 

20 Health to enforce the expanded planning, coordina21 tion, review, and evaluation authority provided the 

22 National Institute on Minority Health and Health 

23 Disparities under section 464z–3(h) of the Public 

24 Health Service Act (42 U.S.C. 285(h)), as added by 

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1 fordable Care Act, over all minority health and 

2 health disparity research that is conducted or sup3 ported by the Institutes and Centers at the National 

4 Institutes of Health; and 

5 (2) the outcomes of such steps. 

6 (c) GAO REPORT RELATED TO RECIPIENTS OF

7 PPACA FUNDING.—Not later than one year after the 

8 date of the enactment of this Act and biennially thereafter 

9 until 2022, the Comptroller General of the United States 

10 shall submit to Congress a report that identifies— 

11 (1) the racial and ethnic diversity of commu12 nity-based organizations that applied for Federal en13 rollment funding provided pursuant to the provisions 

14 of (and amendments made by) the Patient Protec15 tion and Affordable Care Act; 

16 (2) the percentage of such organizations that 

17 were awarded such funding; and 

18 (3) the impact of such community-based organi19 zations’ enrollment efforts on the insurance status of 

20 their communities. 

21 (d) ANNUAL REPORT ON ACTIVITIES OF NATIONAL

22 INSTITUTE ON MINORITY HEALTH AND HEALTH DIS23 PARITIES.—The Director of the National Institute on Mi24 nority Health and Health Disparities shall prepare an an25 nual report on the activities carried out or to be carried 


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1 out by the Institute, and shall submit each such report 

2 to the Committee on Health, Education, Labor, and Pen3 sions of the Senate, the Committee on Energy and Com4 merce of the House of Representatives, the Secretary of 

5 Health and Human Services, and the Director of the Na6 tional Institutes of Health. With respect to the fiscal year 

7 involved, the report shall— 

8 (1) describe and evaluate the progress made in 

9 health disparities research conducted or supported 

10 by institutes and centers of the National Institutes 

11 of Health; 

12 (2) summarize and analyze expenditures made 

13 for activities with respect to health disparities re14 search conducted or supported by the National Insti15 tutes of Health; 

16 (3) include a separate statement applying the 

17 requirements of paragraphs (1) and (2) specifically 

18 to minority health disparities research; and 

19 (4) contain such recommendations as the Direc20 tor of the Institute considers appropriate. 


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1 TITLE X—ADDRESSING SOCIAL 

2 DETERMINANTS AND IM3 PROVING ENVIRONMENTAL 

4 JUSTICE 

5 Subtitle A—In General 

6 SEC. 1001. DEFINITIONS. 

7 (a) DETERMINANTS OF HEALTH.—The term ‘‘deter8 minants of health’’— 

9 (1) refers to the range of personal, social, eco10 nomic, and environmental factors that influence 

11 health status; and 

12 (2) includes social determinants of health 

13 (which are sometimes referred to as ‘‘social and eco14 nomic determinants of health’’ or ‘‘socioeconomic de15 terminants of health’’), environmental determinants 

16 of health, and personal determinants of health. 

17 (b) ENVIRONMENTAL DETERMINANTS OF

18 HEALTH.—The term ‘‘environmental determinants of 

19 health’’ refers to the broad physical, psychological, social, 

20 and aesthetic environment. 

21 (c) PERSONAL DETERMINANTS OF HEALTH.—The 

22 term ‘‘personal determinants of health’’ refers to an indi23 vidual’s behavior, biology, and genetics. 

24 (d) SOCIAL DETERMINANTS OF HEALTH.—The term 

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1 minants of the health of individuals and environments 

2 (such as communities, neighborhoods, and societies) that 

3 describe people’s social identity, describe the social and 

4 economic resources to which people have access, and de5 scribe the conditions in which people work, live, and play. 

6 SEC. 1002. FINDINGS. 

7 The Congress finds as follows: 

8 (1) There are more opportunities to improve 

9 health for everyone when we understand that health 

10 starts, first, not in a medical setting, but in our 

11 families, in our schools and workplaces, in our 

12 neighborhoods, and in the air we breathe and water 

13 we drink. 

14 (2) The social determinants of health are the 

15 largest predictors of health outcomes. 

16 (3) Healthy People 2020 identifies health and 

17 health care quality as a function of not only access 

18 to health care, but also the social determinants of 

19 health, categorized into the following: neighborhoods 

20 and the built environment; social and community 

21 context; education; and economic stability. The fol22 lowing examples illustrate the nexus between the un23 equal distribution of the social determinants of 

24 health and health disparities: 


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1 (A) The built environment influences resi2 dents’ level of physical activity. Neighborhoods 

3 with high levels of poverty are significantly less 

4 likely to have places where children can be 

5 physically active, such as parks, green spaces, 

6 and bike paths and lanes. Neighborhoods and 

7 communities can provide opportunities for phys8 ical activity and support active lifestyles 

9 through accessible and safe parks and open 

10 spaces and through land use policy, zoning, and 

11 healthy community design. 

12 (B) Emotional and physical health and 

13 well-being are directly impacted by perceived 

14 levels of safety, such as unlit streets at night. 

15 Community members have expressed that safety 

16 is not only a barrier to accessing programs and 

17 services that increase quality of life but they 

18 are also not able to access physical activity in 

19 their community through the built environment. 

20 (C) In many workplace environments, toxic 

21 chemicals have lasting detrimental effects on 

22 employees’ health. The hazardous compounds 

23 found in most nail salon products affect the 

24 respiratory system, reproductive system, and 

25 central nervous system, and also cause kidney 


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1 and liver damage. Recognizing the importance 

2 of addressing occupational hazards as a matter 

3 of public health, especially for Asian-American 

4 women who constitute 40 percent of nail salon 

5 technicians—with Vietnamese-American women 

6 accounting for 37 percent of this—the White 

7 House Initiative on Asian American Pacific Is8 landers has created an interagency working 

9 group to coordinate efforts by the Environ10 mental Protection Agency, Occupational and 

11 Safety Health Administration, Food and Drug 

12 Administration, and other Federal agencies to 

13 create programming, draft regulations, and con14 duct more outreach on educating workers on 

15 health and safety issues. 

16 (D) Historical and institutional discrimina17 tion against certain racial groups in the United 

18 States has shaped the way in which social and 

19 economic resources and exposure to health pro20 moting environments are distributed. Income, 

21 education, occupation, neighborhood conditions, 

22 schools, workplaces, the use of and health and 

23 social services, and experiences with the crimi24 nal justice system are all highly patterned by 

25 race, with racial minorities (compared to 


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1 Whites) experiencing more that is health harm2 ing. Finding ways to uncouple the link between 

3 race and access to resources and healthy envi4 ronments is a principal means of reducing 

5 health disparities. Additionally, the anticipation 

6 of racism itself causes higher psychological and 

7 cardiovascular stress levels that are linked to 

8 poor health outcomes. Remedying discrimina9 tory practices at the individual and systemic 

10 levels will likely reduce health disparities caused 

11 by this unequal distribution of stress. 

12 (E) Poor health among Native Americans 

13 has largely been driven by post-colonial oppres14 sion and historical trauma. The expropriation of 

15 native lands and territories to the American 

16 state had severe consequences on Native Amer17 ican health. This resulted in the deprivation of 

18 traditional food sources—and nutrients—for 

19 Native Americans and also the destruction of 

20 traditional economies and community organiza21 tion. Today, Native Americans have twice the 

22 rate of diabetes than non-Hispanic Whites. Rec23 ognition of the origins of the diabetes as having 

24 a social and community context, rather than 

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1 disposition, will shape better policy to provide 

2 food security. 

3 (F) In the context of prisons, overcrowding 

4 has led to the deterioration of the physical and 

5 mental health of individuals after they leave 

6 prison. In particular, the mass incarceration of 

7 African-American males as a result of unequal 

8 contact with and treatment in the criminal jus9 tice system has contributed to an overburdening 

10 of certain infectious diseases within the African11 American community. As a social institution, 

12 incarceration amplifies existing adverse health 

13 conditions by concentrating diseases and harm 

14 health behaviors such as tobacco use, drug use, 

15 and violence. 

16 (G) Educational attainment is the strong17 est predictor of adult mortality. It is a basic 

18 component of socioeconomic status by shaping 

19 earning potential to access resources that pro20 mote health. People with more education are 

21 less likely to report that they are in poor health, 

22 and are also less likely to have diabetes and 

23 other chronic diseases. 

24 (H) Similarly, reading ability is a strong 

25 predictor of adult health status and is often 


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1 correlated with other child health issues, such 

2 as developmental problems, vision and hearing 

3 impairments, and frequent school absence due 

4 to illness. 

5 (I) Individuals with lower levels of edu6 cational attainment are much more likely to re7 port to be current smokers. In 2015, smoking 

8 prevalence was 34.1 percent among adults with 

9 a GED diploma, 24.2 percent with less than a 

10 high school diploma, and 19.8 percent with a 

11 high school diploma, while dropping signifi12 cantly to 7.4 percent among adults with an un13 dergraduate college degree and 3.6 percent with 

14 a postgraduate college degree. 

15 (J) Social class differences account for a 

16 large part of health disparities. For example, 

17 children living in poverty experience poorer 

18 housing conditions, increased exposure to in19 door allergens and toxins (such as pesticides, 

20 lead, mercury, radon, air pollution, and carcino21 gens), and more psychological stress. These ex22 periences culminate in worse adult health as 

23 compared with children with higher socio24 economic status. Specifically, children living in 

25 socioeconomic neighborhoods have higher rates 


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1 of asthma due to higher rates of psychological 

2 stress resulting from higher rates of violence. 

3 (K) Lesbian, gay, bisexual, transgender, 

4 queer, questioning, questioning and intersex 

5 (LGBTQIA) individuals face health disparities 

6 linked to societal stigma, discrimination, and 

7 denial of their civil and human rights. Discrimi8 nation against LGBTQIA individuals has been 

9 associated with high rates of psychiatric dis10 orders, substance abuse, and suicide. Experi11 ences of violence and victimization are frequent 

12 for LGBTQIA individuals, and have long-last13 ing effects on the individual and the commu14 nity. Personal, family, and social acceptance of 

15 sexual orientation and gender identity affects 

16 the mental health and personal safety of 

17 LGBTQIA individuals. 

18 (L) Individuals in older and cheaper hous19 ing are at higher risks to be exposed to lead, 

20 particularly in housing built prior to 1960. The 

21 threat of lead poisoning disproportionally af22 fects vulnerable populations, with children living 

23 in poverty (5.6 percent) and Black children 

24 (5.6) experiencing the highest rates. According 

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1 velopment, about 3.6 million homes nationwide 

2 that house young children have lead hazards 

3 such as peeling paint, contaminated dust, or 

4 toxic soil. The combined cost of medical treat5 ment and special education for lead poisoned 

6 children averages about $5,600 per child per 

7 year, and lead poisoning costs the United 

8 States an estimated $50 billion annually. 

9 (4) Laws and regulations that improve opportu10 nities to live in safe neighborhoods, with more social 

11 cohesion, attain higher education, sustain stable em12 ployment, and bridge class differences help foster 

13 the health and safety of individuals. 

14 (5) The global public health community has 

15 reached consensus through the Rio Political Declara16 tion of Social Determinants of Health that 

17 ‘‘[c]ollaboration in coordinated and intersectoral pol18 icy actions has proven to be effective. Health in All 

19 Policies, together with intersectoral cooperation and 

20 action, is one promising approach to enhance ac21 countability in other sectors of health, as well as the 

22 promotion of health equity and more inclusive and 

23 productive societies.’’. 


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1 SEC. 1003. HEALTH IMPACT ASSESSMENTS. 

2 (a) FINDINGS.—Congress makes the following find3 ings: 

4 (1) Health Impact Assessment is a tool to help 

5 planners, health officials, decisionmakers, and the 

6 public make more informed decisions about the po7 tential health effects of proposed plans, policies, pro8 grams, and projects in order to maximize health 

9 benefits and minimize harms. 

10 (2) Health Impact Assessments can be done at 

11 a fraction of the cost and time typically required for 

12 other planning and permitting reviews. 

13 (3) Health Impact Assessments can build com14 munity support and reduce opposition to a project or 

15 policy, thereby facilitating economic growth by aid16 ing the development of consensus regarding new de17 velopment proposals. 

18 (4) Health Impact Assessments facilitate col19 laboration across sectors. 

20 (b) PURPOSES.—It is the purpose of this section to— 

21 (1) provide more information about the poten22 tial human health effects of policy decisions and the 

23 distribution of those effects; 

24 (2) improve how health is considered in plan25 ning and decisionmaking processes; and 


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1 (3) build stronger, healthier communities 

2 through the use of Health Impact Assessment. 

3 (c) HEALTH IMPACT ASSESSMENTS.—Part P of title 

4 III of the Public Health Service Act (42 U.S.C. 280g et 

5 seq.), as amended, is further amended by adding at the 

6 end the following: 

7 ‘‘SEC. 399V–12. HEALTH IMPACT ASSESSMENTS. 

8 ‘‘(a) DEFINITIONS.—In this section and section 

9 399V–13: 

10 ‘‘(1) ADMINISTRATOR.—The term ‘Adminis11 trator’ means the Administrator of the Environ12 mental Protection Agency. 

13 ‘‘(2) BUILT ENVIRONMENT.—The term ‘built 

14 environment’ means the components of the environ15 ment, and the location of these components in a geo16 graphically defined space, that are created or modi17 fied by individuals to form the physical and social 

18 characteristics of a community or enhance quality of 

19 human life, including— 

20 ‘‘(A) homes, schools, and places of work 

21 and worship; 

22 ‘‘(B) parks, recreation areas, and green23 ways; 

24 ‘‘(C) transportation systems; 


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1 ‘‘(D) business, industry, and agriculture; 

2 and 

3 ‘‘(E) land-use plans, projects, and policies 

4 that impact the physical or social characteris5 tics of a community, including access to services 

6 and amenities. 

7 ‘‘(3) DIRECTOR.—The term ‘Director’ means 

8 the Director of the Centers for Disease Control and 

9 Prevention. 

10 ‘‘(4) ELIGIBLE ENTITY.—The term ‘eligible en11 tity’ means a unit of State or Tribal government the 

12 jurisdiction of which includes individuals or popu13 lations the health of which are, or will be, affected 

14 by an activity or a proposed activity. 

15 ‘‘(5) ELIGIBLE INSTITUTION.—The term ‘eligi16 ble institution’ means a public agency or private 

17 nonprofit institution that submits to the Secretary, 

18 in consultation with the Administrator, an applica19 tion for a grant authorized under such section at 

20 such time, in such manner, and containing such 

21 agreements, assurances, and information as the Sec22 retary and Administrator may require. 

23 ‘‘(6) HEALTH IMPACT ASSESSMENT.—The term 

24 ‘Health Impact Assessment’ means a systematic 

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1 lytic methods and considers input from stakeholders 

2 to determine the potential effects of a proposed pol3 icy, plan, program, or project on the health of a pop4 ulation and the distribution of those effects within 

5 the population. Such term includes identifying and 

6 recommending appropriate actions on monitoring 

7 and maximizing potential benefits and minimizing 

8 the potential harms. 

9 ‘‘(7) HEALTH DISPARITIES.—The term ‘health 

10 disparities’ are a particular type of health dif11 ferences that are closely linked with social, economic, 

12 and/or environmental disadvantage. Health dispari13 ties adversely affect groups of people who have sys14 tematically experienced greater obstacles to health 

15 based on their racial or ethnic group; religion; socio16 economic status; gender; age; mental health; cog17 nitive, sensory, or physical disability; sexual orienta18 tion or gender identity; geographic location; or other 

19 characteristics historically linked to discrimination 

20 or exclusion. 

21 ‘‘(8) PROPOSED ACTIVITY.—The term ‘proposed 

22 activity’ means a proposed policy, program, plan, or 

23 project currently under consideration by a local, 

24 State, Tribal, or Federal agency or government. 


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1 ‘‘(b) ESTABLISHMENT.—The Secretary, acting 

2 through the Director and in collaboration with the Admin3 istrator, shall carry out the following: 

4 ‘‘(1) Establish a program at the National Cen5 ter for Environmental Health at the Centers for Dis6 ease Control and Prevention focused on advancing 

7 the field of Health Impact Assessment. In devel8 oping and implementing the program, the Director 

9 of the National Center for Environmental Health 

10 shall consult with the Director of the National Cen11 ter for Chronic Disease Prevention and Health Pro12 motion as well as relevant offices within the Depart13 ment of Housing and Urban Development, the De14 partment of Transportation, and the Department of 

15 Agriculture. The program shall include— 

16 ‘‘(A) collecting and disseminating best 

17 practices; 

18 ‘‘(B) administering capacity building 

19 grants to States to support grantees in initi20 ating Health Impact Assessments, in accord21 ance with subsection (d); 

22 ‘‘(C) providing technical assistance; 

23 ‘‘(D) developing training tools and pro24 viding training on conducting Health Impact 


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1 Assessment and the implementation of built en2 vironment and health indicators; 

3 ‘‘(E) making information available, as ap4 propriate, regarding the existence of other com5 munity healthy living tools, checklists, and indi6 ces that help connect public health to other sec7 tors, and tools to help examine the effect of the 

8 indoor built environment and building codes on 

9 population health; 

10 ‘‘(F) conducting research and evaluations 

11 of Health Impact Assessments; and 

12 ‘‘(G) awarding competitive extramural re13 search grants. 

14 ‘‘(2) In accordance with subsection (c), develop 

15 guidance and guidelines to conduct Health Impact 

16 Assessments. 

17 ‘‘(3) In accordance with subsection (d), estab18 lish a grant program to allow States to fund eligible 

19 entities to conduct Health Impact Assessments. 

20 ‘‘(c) GUIDANCE.—The Director, in consultation with 

21 the Director of the National Center for Environmental 

22 Health and, the Director of the National Center for 

23 Chronic Disease Prevention and Health Promotion, and 

24 relevant offices within the Department of Housing and 


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1 Urban Development, the Department of Transportation, 

2 and the Department of Agriculture, shall— 

3 ‘‘(1) develop guidance for conducting Health 

4 Impact Assessment, including— 

5 ‘‘(A) background on national and inter6 national efforts to bridge urban planning and 

7 public health institutions and disciplines, in8 cluding a review of Health Impact Assessment 

9 best practices internationally; 

10 ‘‘(B) evidence-based direct and indirect 

11 pathways that link land-use planning, transpor12 tation, and housing policy and objectives to 

13 human health outcomes; 

14 ‘‘(C) data resources and quantitative and 

15 qualitative forecasting methods to evaluate both 

16 the status of health determinants and health ef17 fects, including identification of existing pro18 grams that can disseminate these resources; 

19 ‘‘(D) best practices for inclusive public in20 volvement in conducting Health Impact Assess21 ments; and 

22 ‘‘(E) technical assistance for other agen23 cies seeking to develop their own guidelines and 

24 procedures for Health Impact Assessment; 


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1 ‘‘(2) in developing the guidance, consider avail2 able international Health Impact Assessment guid3 ance, North American Health Impact Assessment 

4 Practice Standards, and recommendations from the 

5 National Academy of Science; and 

6 ‘‘(3) not later than 1 year after the date of en7 actment of this section, publish the guidance. 

8 ‘‘(d) GRANT PROGRAM.—The Secretary, acting 

9 through the Director and in collaboration with the Admin10 istrator, shall establish a program under which the Sec11 retary shall award grants to States to fund eligible entities 

12 for capacity building or to prepare Health Impact Assess13 ments, and shall ensure that States receiving a grant 

14 under this subsection further support training and tech15 nical assistance for grantees under the program by fund16 ing and overseeing appropriate local, State, Tribal, Fed17 eral, university, or nonprofit Health Impact Assessment 

18 experts to provide technical assistance. Such assessments 

19 shall— 

20 ‘‘(1) ensure that appropriate health factors are 

21 taken into consideration as early as practicable dur22 ing the planning, review, or decisionmaking proc23 esses; 

24 ‘‘(2) assess the effect on the health of individ25 uals and populations of proposed policies, projects, 


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1 or plans that result in modifications to the built en2 vironment; and 

3 ‘‘(3) assess the distribution of health effects 

4 across various factors, such as race, income, eth5 nicity, age, disability status, gender, and geography. 

6 ‘‘(e) APPLICATIONS.— 

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

8 grant under this section, an eligible entity shall sub9 mit to the Secretary an application in accordance 

10 with this subsection, at such time, in such manner, 

11 and containing such additional information as the 

12 Secretary may require. 

13 ‘‘(2) INCLUSION.—An application under this 

14 subsection shall include a list of proposed activities 

15 that require or would benefit from conducting a 

16 Health Impact Assessment within six months of 

17 awarding funds. The list should be accompanied by 

18 supporting documentation, including letters of sup19 port, from potential conductors of Health Impact 

20 Assessments for the listed proposed activities. Each 

21 application should also include an assessment by the 

22 eligible entity of the health of the population of its 

23 jurisdiction and describe potential adverse or positive 

24 effects on health that the proposed activities may 

25 create. 


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1 ‘‘(3) PREFERENCE.—Preference in awarding 

2 funds under this section may be given to eligible en3 tities that demonstrate the potential to significantly 

4 improve population health or lower health care costs 

5 as a result of potential Health Impact Assessment 

6 work. 

7 ‘‘(f) USE OF FUNDS.— 

8 ‘‘(1) IN GENERAL.—An eligible entity shall use 

9 amounts provided under a grant under this section 

10 to conduct Health Impact Assessment capacity 

11 building or to conduct or fund subgrantees to con12 duct a Health Impact Assessment for a proposed ac13 tivity in accordance with this subsection. 

14 ‘‘(2) PURPOSES.—The purposes of a Health 

15 Impact Assessment under this subsection are— 

16 ‘‘(A) to facilitate the involvement of Tribal, 

17 State, and local public health officials in com18 munity planning, transportation, housing, and 

19 land use decisions and other decisions affecting 

20 the built environment to identify any potential 

21 health concern or health benefit relating to an 

22 activity or proposed activity; 

23 ‘‘(B) to provide for an investigation of any 

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1 ment process, or policy appraisal relating to a 

2 proposed activity; 

3 ‘‘(C) to describe and compare alternatives 

4 (including no-action alternatives) to a proposed 

5 activity to provide clarification with respect to 

6 the potential health outcomes associated with 

7 the proposed activity and, where appropriate, to 

8 the related benefit-cost or cost-effectiveness of 

9 the proposed activity and alternatives; 

10 ‘‘(D) to contribute, when applicable, to the 

11 findings of a planning process, policy appraisal, 

12 or an environmental impact statement with re13 spect to the terms and conditions of imple14 menting a proposed activity or related mitiga15 tion recommendations, as necessary; 

16 ‘‘(E) to ensure that the disproportionate 

17 distribution of negative impacts among vulner18 able populations is minimized as much as pos19 sible; 

20 ‘‘(F) to engage affected community mem21 bers and ensure adequate opportunity for public 

22 comment on all stages of the Health Impact As23 sessment; 

24 ‘‘(G) where appropriate, to consult with 

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1 priate organizations, including planning, trans2 portation, and housing organizations and pro3 viding them with information and tools regard4 ing how to conduct and integrate Health Im5 pact Assessment into their work; and 

6 ‘‘(H) to inspect homes, water systems, and 

7 other elements that pose risks to lead exposure, 

8 with an emphasis on areas that pose a higher 

9 risk to children. 

10 ‘‘(3) ELIGIBLE ACTIVITIES.— 

11 ‘‘(A) IN GENERAL.—Eligible entities fund12 ed under this subsection shall conduct an eval13 uation of any proposed activity to determine 

14 whether it will have a significant adverse or 

15 positive effect on the health of the affected pop16 ulation in the jurisdiction of the eligible entity, 

17 based on the criteria described in subparagraph 

18 (B). 

19 ‘‘(B) CRITERIA.—The criteria described in 

20 this subparagraph include, as applicable to the 

21 proposed activity, the following: 

22 ‘‘(i) Any substantial adverse effect or 

23 significant health benefit on health out24 comes or factors known to influence health, 

25 including the following: 


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1 ‘‘(I) Physical activity. 

2 ‘‘(II) Injury. 

3 ‘‘(III) Mental health. 

4 ‘‘(IV) Accessibility to health-pro5 moting goods and services. 

6 ‘‘(V) Respiratory health. 

7 ‘‘(VI) Chronic disease. 

8 ‘‘(VII) Nutrition. 

9 ‘‘(VIII) Land use changes that 

10 promote local, sustainable food 

11 sources. 

12 ‘‘(IX) Infectious disease. 

13 ‘‘(X) Health disparities. 

14 ‘‘(XI) Existing air quality, 

15 ground or surface water quality or 

16 quantity, or noise levels. 

17 ‘‘(XII) Lead exposure. 

18 ‘‘(ii) Other factors that may be con19 sidered, including— 

20 ‘‘(I) the potential for a proposed 

21 activity to result in systems failure 

22 that leads to a public health emer23 gency; 

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1 cant increase in tourism, economic de2 velopment, or employment in the ju3 risdiction of the eligible entity; 

4 ‘‘(III) any other significant po5 tential hazard or enhancement to 

6 human health, as determined by the 

7 eligible entity; or 

8 ‘‘(IV) whether the evaluation of a 

9 proposed activity would duplicate an10 other analysis or study being under11 taken in conjunction with the pro12 posed activity. 

13 ‘‘(C) FACTORS FOR CONSIDERATION.—In 

14 evaluating a proposed activity under subpara15 graph (A), an eligible entity may take into con16 sideration any reasonable, direct, indirect, or 

17 cumulative effect that can be clearly related to 

18 potential health effects and that is related to 

19 the proposed activity, including the effect of 

20 any action that is— 

21 ‘‘(i) included in the long-range plan 

22 relating to the proposed activity; 

23 ‘‘(ii) likely to be carried out in coordi24 nation with the proposed activity; 


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1 ‘‘(iii) dependent on the occurrence of 

2 the proposed activity; or 

3 ‘‘(iv) likely to have a disproportionate 

4 impact on high-risk or vulnerable popu5 lations. 

6 ‘‘(4) REQUIREMENTS.—A Health Impact As7 sessment prepared with funds awarded under this 

8 subsection shall incorporate the following, after con9 ducting the screening phase (identifying projects or 

10 policies for which a Health Impact Assessment 

11 would be valuable and feasible) through the applica12 tion process: 

13 ‘‘(A) SCOPING.—Identifying which health 

14 effects to consider and the research methods to 

15 be utilized. 

16 ‘‘(B) ASSESSING RISKS AND BENEFITS.— 

17 Assessing the baseline health status and factors 

18 known to influence the health status in the af19 fected community, which may include aggre20 gating and synthesizing existing health assess21 ment evidence and data from the community. 

22 ‘‘(C) DEVELOPING RECOMMENDATIONS.— 

23 Suggesting changes to proposals to promote 

24 positive or mitigate adverse health effects. 


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1 ‘‘(D) REPORTING.—Synthesizing the as2 sessment and recommendations and commu3 nicating the results to decisionmakers. 

4 ‘‘(E) MONITORING AND EVALUATING.— 

5 Tracking the decision and implementation effect 

6 on health determinants and health status. 

7 ‘‘(5) PLAN.—An eligible entity that is awarded 

8 a grant under this section shall develop and imple9 ment a plan, to be approved by the Director, for 

10 meaningful and inclusive stakeholder involvement in 

11 all phases of the Health Impact Assessment. Stake12 holders may include community-based organizations, 

13 youth-serving organizations, planners, public health 

14 experts, State and local public health departments 

15 and officials, health care experts or officials, housing 

16 experts or officials, and transportation experts or of17 ficials. 

18 ‘‘(6) SUBMISSION OF FINDINGS.—An eligible 

19 entity that is awarded a grant under this section 

20 shall submit the findings of any funded Health Im21 pact Assessment activities to the Secretary and 

22 make these findings publicly available. 

23 ‘‘(7) ASSESSMENT OF IMPACTS.—An eligible en24 tity that is awarded a grant under this section shall 

25 ensure the assessment of the distribution of health 


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1 impacts (related to the proposed activity) across 

2 race, ethnicity, income, age, gender, disability status, 

3 and geography. 

4 ‘‘(8) CONDUCT OF ASSESSMENT.—To the great5 est extent feasible, a Health Impact Assessment 

6 shall be conducted under this section in a manner 

7 that respects the needs and timing of the decision8 making process it evaluates. 

9 ‘‘(9) METHODOLOGY.—In preparing a Health 

10 Impact Assessment under this subsection, an eligible 

11 entity or partner shall follow the guidance published 

12 under subsection (c). 

13 ‘‘(g) HEALTH IMPACT ASSESSMENT DATABASE.— 

14 The Secretary, acting through the Director and in collabo15 ration with the Administrator, shall establish, maintain, 

16 and make publicly available a Health Impact Assessment 

17 database, including— 

18 ‘‘(1) a catalog of Health Impact Assessments 

19 received under this section; 

20 ‘‘(2) an inventory of tools used by eligible enti21 ties to conduct Health Impact Assessments; and 

22 ‘‘(3) guidance for eligible entities with respect 

23 to the selection of appropriate tools described in 

24 paragraph (2). 


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1 ‘‘(h) EVALUATION OF GRANTEE ACTIVITIES.—The 

2 Secretary shall award competitive grants to Prevention 

3 Research Centers, or nonprofit organizations or academic 

4 institutions with expertise in Health Impact Assessments 

5 to— 

6 ‘‘(1) assist grantees with the provision of train7 ing and technical assistance in the conducting of 

8 Health Impact Assessments; 

9 ‘‘(2) evaluate the activities carried out with 

10 grants under subsection (d); and 

11 ‘‘(3) assist the Secretary in disseminating evi12 dence, best practices, and lessons learned from 

13 grantees. 

14 ‘‘(i) REPORT TO CONGRESS.—Not later than 1 year 

15 after the date of enactment of this section, the Secretary 

16 shall submit to Congress a report concerning the evalua17 tion of the programs under this section, including rec18 ommendations as to how lessons learned from such pro19 grams can be incorporated into future guidance docu20 ments developed and provided by the Secretary and other 

21 Federal agencies, as appropriate. 

22 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—There 

23 are authorized to be appropriated to carry out this section 

24 such sums as may be necessary. 


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1 ‘‘SEC. 399V–13. IMPLEMENTATION OF RESEARCH FINDINGS 

2 TO IMPROVE HEALTH OUTCOMES THROUGH 

3 THE BUILT ENVIRONMENT. 

4 ‘‘(a) RESEARCH GRANT PROGRAM.— 

5 ‘‘(1) GRANTS.—The Secretary, in collaboration 

6 with the Administrator, shall award grants to eligi7 ble institutions to implement evidence-based pro8 gramming to improve the built environment and sub9 sequently human health. Factors that influence 

10 health that may be considered include— 

11 ‘‘(A) levels of physical activity; 

12 ‘‘(B) consumption of nutritional foods; 

13 ‘‘(C) rates of crime; 

14 ‘‘(D) air, water, and soil quality; 

15 ‘‘(E) risk or rate of injury; 

16 ‘‘(F) accessibility to health-promoting 

17 goods and services; 

18 ‘‘(G) chronic disease rates; 

19 ‘‘(H) community design; 

20 ‘‘(I) housing; and 

21 ‘‘(J) other indicators as determined appro22 priate by the Secretary. 

23 ‘‘(2) RESEARCH.—The Secretary, in consulta24 tion with the Administrator, shall support research 

25 under this section that— 


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1 ‘‘(A) uses evidence-based research to im2 prove the built environment and human health; 

3 ‘‘(B) examines— 

4 ‘‘(i) the scope and intensity of the im5 pact that the built environment (including 

6 the various characteristics of the built en7 vironment) has on the human health; or 

8 ‘‘(ii) the distribution of such impacts 

9 by— 

10 ‘‘(I) location; and 

11 ‘‘(II) population subgroup; 

12 ‘‘(C) is used to develop— 

13 ‘‘(i) measures and indicators to ad14 dress health impacts and the connection of 

15 health to the built environment; 

16 ‘‘(ii) efforts to link the measures to 

17 transportation, land use, and health data18 bases; and 

19 ‘‘(iii) efforts to enhance the collection 

20 of built environment surveillance data; 

21 ‘‘(D) distinguishes carefully between per22 sonal attitudes and choices and external influ23 ences on behavior to determine how much the 

24 association between the built environment and 

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1 erences of the people that choose to live in the 

2 neighborhood, reflects the physical characteris3 tics of the neighborhood; and 

4 ‘‘(E)(i) identifies or develops effective 

5 intervention strategies focusing on enhance6 ments to the built environment that promote in7 creased use physical activity, access to nutri8 tious foods, or other health-promoting activities 

9 by residents; and 

10 ‘‘(ii) in developing the intervention strate11 gies under clause (i), ensures that the interven12 tion strategies will reach out to high-risk or vul13 nerable populations, including low-income urban 

14 and rural communities and aging populations, 

15 in addition to the general population. 

16 ‘‘(3) SURVEYS.—The Secretary may use funds 

17 appropriated under this section to support the ex18 pansion of national surveys and data tracking sys19 tems to provide more detailed information about the 

20 connection between the built environment and 

21 health. 

22 ‘‘(4) PRIORITY.—In providing assistance under 

23 the grant program under this section, the Secretary 

24 and the Administrator shall give priority to pro25 gramming that incorporates— 


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1 ‘‘(A) interdisciplinary approaches; or 

2 ‘‘(B) the expertise of the public health, 

3 physical activity, urban planning, land use, and 

4 transportation research communities in the 

5 United States and abroad. 

6 ‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—There 

7 are authorized to be appropriated such sums as may be 

8 necessary to carry out this section. Not to exceed 20 per9 cent of amounts appropriated for each fiscal year under 

10 this subsection may be used for the research component 

11 of the program under this section.’’. 

12 SEC. 1004. IMPLEMENTATION OF RECOMMENDATIONS BY 

13 ENVIRONMENTAL PROTECTION AGENCY. 

14 (a) INSPECTOR GENERAL RECOMMENDATIONS.—The 

15 Administrator of the Environmental Protection Agency 

16 shall, as promptly as practicable, carry out each of the 

17 following recommendations of the Inspector General of the 

18 Agency as set forth in Report No. 2006–P–00034 entitled 

19 ‘‘EPA needs to conduct environmental justice reviews of 

20 its programs, policies and activities’’: 

21 (1) The recommendation that the Agency’s pro22 gram and regional offices identify which programs, 

23 policies, and activities need environmental justice re24 views and require these offices to establish a plan to 

25 complete the necessary reviews. 


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1 (2) The recommendation that the Administrator 

2 of the Agency ensure that these reviews determine 

3 whether the programs, policies, and activities may 

4 have a disproportionately high and adverse health or 

5 environmental impact on minority and low-income 

6 populations. 

7 (3) The recommendation that each program 

8 and regional office develop specific environmental 

9 justice review guidance for conducting environmental 

10 justice reviews. 

11 (4) The recommendation that the Administrator 

12 designate a responsible office to compile results of 

13 environmental justice reviews and recommend appro14 priate actions. 

15 (b) GAO RECOMMENDATIONS.—In developing rules 

16 under laws administered by the Environmental Protection 

17 Agency, the Administrator of the Agency shall, as prompt18 ly as practicable, carry out each of the following rec19 ommendations of the Comptroller General of the United 

20 States as set forth in GAO Report numbered GAO–05– 

21 289 entitled ‘‘EPA Should Devote More Attention to En22 vironmental Justice when Developing Clean Air Rules’’: 

23 (1) The recommendation that the Administrator 

24 ensure that workgroups involved in developing a rule 


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1 devote attention to environmental justice while draft2 ing and finalizing the rule. 

3 (2) The recommendation that the Administrator 

4 enhance the ability of such workgroups to identify 

5 potential environmental justice issues through such 

6 steps as providing workgroup members with guid7 ance and training to help them identify potential en8 vironmental justice problems and involving environ9 mental justice coordinators in the workgroups when 

10 appropriate. 

11 (3) The recommendation that the Administrator 

12 improve assessments of potential environmental jus13 tice impacts in economic reviews by identifying the 

14 data and developing the modeling techniques needed 

15 to assess such impacts. 

16 (4) The recommendation that the Administrator 

17 direct appropriate Agency officers and employees to 

18 respond fully when feasible to public comments on 

19 environmental justice, including improving the Agen20 cy’s explanation of the basis for its conclusions, to21 gether with supporting data. 

22 (c) 2004 INSPECTOR GENERAL REPORT.—The Ad23 ministrator of the Environmental Protection Agency shall, 

24 as promptly as practicable, carry out each of the following 

25 recommendations of the Inspector General of the Agency 


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1 as set forth in the report entitled ‘‘EPA Needs to Consist2 ently Implement the Intent of the Executive Order on En3 vironmental Justice’’ (Report No. 2004–P–00007): 

4 (1) The recommendation that the Agency clear5 ly define the mission of the Office of Environmental 

6 Justice (OEJ) and provide Agency staff with an un7 derstanding of the roles and responsibilities of the 

8 Office. 

9 (2) The recommendation that the Agency estab10 lish (through issuing guidance or a policy statement 

11 from the Administrator) specific timeframes for the 

12 development of definitions, goals, and measurements 

13 regarding environmental justice and provide the re14 gions and program offices a standard and consistent 

15 definition for a minority and low-income community, 

16 with instructions on how the Agency will implement 

17 and put into operation environmental justice in the 

18 Agency’s daily activities. 

19 (3) The recommendation that the Agency en20 sure the comprehensive training program currently 

21 under development includes standard and consistent 

22 definitions of the key environmental justice concepts 

23 (such as ‘‘low-income’’, ‘‘minority’’, and ‘‘dispropor24 tionately impacted’’) and instructions for implemen25 tation of those concepts. 


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1 The Administrator shall submit an initial report to Con2 gress within 6 months after the enactment of this Act re3 garding the Administrator’s strategy for implementing the 

4 recommendations referred to in paragraphs (1), (2), and 

5 (3). Thereafter, the Administrator shall provide semi6 annual reports to Congress regarding the Administrator’s 

7 progress in implementing such recommendations and 

8 modifying the Administrator’s emergency management 

9 procedures to incorporate environmental justice in the 

10 Agency’s Incident Command Structure (in accordance 

11 with the December 18, 2006, letter from the Deputy Ad12 ministrator to the Acting Inspector General of the Agen13 cy). 

14 (d) FEDERAL ACTION PLAN FOR SAVING LIVES, 

15 PROTECTING PEOPLE AND THEIR FAMILIES FROM

16 RADON.— 

17 (1) IN GENERAL.—Because radon is a naturally 

18 occurring radioactive gas that is recognized as the 

19 leading cause of lung cancer among nonsmokers and 

20 is a particular environmental threat for low-income 

21 and minority individuals because of the lack of infor22 mation about radon levels in their own homes, the 

23 Administrator of the Environmental Protection 

24 Agency shall within 6 months after the date of the 

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1 titled ‘‘Protecting People and Families from Radon: 

2 A Federal Action Plan for Saving Lives’’ (June 20, 

3 2011), working with the Secretary of Health and 

4 Human Services acting through the Director of the 

5 Centers for Disease Control and Prevention, and 

6 with the other Federal agencies mentioned in and as 

7 set forth in the action plan. 

8 (2) SPECIFIC STEPS.—In carrying out para9 graph (1), the Administrator shall take steps to 

10 achieve each of the following: 

11 (A) The recommendation that the 

12 workgroup comprised of the Federal agencies 

13 participating in the development of the action 

14 plan referred to in paragraph (1) implement 

15 specific steps within the current authority and 

16 activities of each Federal agency to reduce ex17 posure to radon. 

18 (B) The recommendation that such 

19 workgroup meet on the 1-year anniversary of 

20 the plan to assess and recognize achievements 

21 of the plan. 

22 (3) REPORT.—The Administrator shall report 

23 to the Congress on the 1-year assessment of the 

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1 sure particularly to low-income and minority fami2 lies. 

3 (e) FEDERAL ACTION PLAN FOR PREVENTING

4 CHILDHOOD LEAD POISONING.— 

5 (1) FINDINGS.—The Congress finds the fol6 lowing: 

7 (A) The effects of lead poisoning are irre8 versible and cost the United States millions an9 nually in medical and education costs. 

10 (B) The cognitive effects suffered by lead 

11 exposed children result in a lifetime of health 

12 and behavioral problems, which makes preven13 tion efforts more critical. 

14 (C) The risk is especially high for vulner15 able minority populations who are more likely 

16 to live in older homes, where lead-based paint 

17 is more likely to be present. 

18 (2) ACTION PLAN.—The Administrator of the 

19 Environmental Protection Agency shall, not later 

20 than 6 months after the date of the enactment of 

21 this Act, develop an action plan, working with the 

22 Secretary of Health and Human Services acting 

23 through the Director of the Centers for Disease 

24 Control and Prevention, and other Federal agencies 

25 as necessary. 


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1 (3) SPECIFIC STEPS.—In carrying out para2 graph (2), the Administrator of the Environmental 

3 Protection Agency shall take steps to achieve each of 

4 the following: 

5 (A) The establishment of a working group, 

6 comprised of representatives of the Federal 

7 agencies participating in the development of the 

8 action plan referred to in paragraph (2), to 

9 make recommendations for implementation of 

10 specific steps within the existing authority and 

11 activities of each Federal agency to reduce ex12 posure to lead. 

13 (B) The development by Federal agencies 

14 of materials on the hazards of lead-based paint 

15 aimed at educating tenants and landlords, and 

16 how to both recognize potential causes for expo17 sure and how to remediate them. 

18 SEC. 1005. GRANT PROGRAM TO CONDUCT ENVIRON19 MENTAL HEALTH IMPROVEMENT ACTIVITIES 

20 AND TO IMPROVE SOCIAL DETERMINANTS OF 

21 HEALTH. 

22 (a) DEFINITIONS.—In this section: 

23 (1) DIRECTOR.—The term ‘‘Director’’ means 

24 the Director of the Centers for Disease Control and 

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1 trator of the Environmental Protection Agency and 

2 the Director of the National Institute of Environ3 mental Health Sciences. 

4 (2) ELIGIBLE ENTITY.—The term ‘‘eligible enti5 ty’’ means a State or local community that— 

6 (A) bears a disproportionate burden of ex7 posure to environmental health hazards; 

8 (B) bears a disproportionate burden of ex9 posure to unhealthy living conditions, low 

10 standard housing conditions, low socioeconomic 

11 status, poor nutrition, less opportunity for edu12 cational attainment, disproportionate unemploy13 ment rates, or lower literacy levels; 

14 (C) has established a coalition— 

15 (i) with not less than 1 community16 based organization or demonstration pro17 gram; and 

18 (ii) with not less than 1— 

19 (I) public health entity; 

20 (II) health care provider organi21 zation; 

22 (III) academic institution, includ23 ing any minority-serving institution 

24 (including a Hispanic-serving institu25 tion, a historically Black college or 


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1 university, and a Tribal college or uni2 versity); 

3 (IV) child-serving institution; or 

4 (V) landlord or housing provider 

5 working on lead remediation; 

6 (D) ensures planned activities and funding 

7 streams are coordinated to improve community 

8 health; and 

9 (E) submits an application in accordance 

10 with subsection (c). 

11 (b) ESTABLISHMENT.—The Director shall establish a 

12 grant program under which eligible entities shall receive 

13 grants to conduct environmental health improvement ac14 tivities and to improve social determinants of health. 

15 (c) APPLICATION.—To receive a grant under this sec16 tion, an eligible entity shall submit an application to the 

17 Director at such time, in such manner, and accompanied 

18 by such information as the Director may require. 

19 (d) COOPERATIVE AGREEMENTS.—An eligible entity 

20 may use a grant under this section— 

21 (1) to promote environmental health; 

22 (2) to address environmental health disparities 

23 among all populations, including children; and 

24 (3) to address racial and ethnic disparities in 

25 social determinants of health. 


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1 (e) AMOUNT OF COOPERATIVE AGREEMENT.— 

2 (1) IN GENERAL.—The Director shall award 

3 grants to eligible entities at the 3 different funding 

4 levels described in this subsection. 

5 (2) LEVEL 1 COOPERATIVE AGREEMENTS.— 

6 (A) IN GENERAL.—An eligible entity 

7 awarded a grant under this paragraph shall use 

8 the funds to identify environmental health prob9 lems and solutions by— 

10 (i) establishing a planning and 

11 prioritizing council in accordance with sub12 paragraph (B); and 

13 (ii) conducting an environmental 

14 health assessment in accordance with sub15 paragraph (C). 

16 (B) PLANNING AND PRIORITIZING COUN17 CIL.— 

18 (i) IN GENERAL.—A prioritizing and 

19 planning council established under sub20 paragraph (A)(i) (referred to in this para21 graph as a ‘‘PPC’’) shall assist the envi22 ronmental health assessment process and 

23 environmental health promotion activities 

24 of the eligible entity. 


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1 (ii) MEMBERSHIP.—Membership of a 

2 PPC shall consist of representatives from 

3 various organizations within public health, 

4 planning, development, and environmental 

5 services and shall include stakeholders 

6 from vulnerable groups such as children, 

7 the elderly, disabled, and minority ethnic 

8 groups that are often not actively involved 

9 in democratic or decisionmaking processes. 

10 (iii) DUTIES.—A PPC shall— 

11 (I) identify key stakeholders and 

12 engage and coordinate potential part13 ners in the planning process; 

14 (II) establish a formal advisory 

15 group to plan for the establishment of 

16 services; 

17 (III) conduct an in-depth review 

18 of the nature and extent of the need 

19 for an environmental health assess20 ment, including a local epidemiological 

21 profile, an evaluation of the service 

22 provider capacity of the community, 

23 and a profile of any target popu24 lations; and 


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1 (IV) define the components of 

2 care and form essential programmatic 

3 linkages with related providers in the 

4 community. 

5 (C) ENVIRONMENTAL HEALTH ASSESS6 MENT.— 

7 (i) IN GENERAL.—A PPC shall carry 

8 out an environmental health assessment to 

9 identify environmental health concerns. 

10 (ii) ASSESSMENT PROCESS.—The 

11 PPC shall— 

12 (I) define the goals of the assess13 ment; 

14 (II) generate the environmental 

15 health issue list; 

16 (III) analyze issues with a sys17 tems framework; 

18 (IV) develop appropriate commu19 nity environmental health indicators; 

20 (V) rank the environmental 

21 health issues; 

22 (VI) set priorities for action; 

23 (VII) develop an action plan; 

24 (VIII) implement the plan; and 


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1 (IX) evaluate progress and plan2 ning for the future. 

3 (D) EVALUATION.—Each eligible entity 

4 that receives a grant under this paragraph shall 

5 evaluate, report, and disseminate program find6 ings and outcomes. 

7 (E) TECHNICAL ASSISTANCE.—The Direc8 tor may provide such technical and other non9 financial assistance to eligible entities as the 

10 Director determines to be necessary. 

11 (3) LEVEL 2 COOPERATIVE AGREEMENTS.— 

12 (A) ELIGIBILITY.— 

13 (i) IN GENERAL.—The Director shall 

14 award grants under this paragraph to eli15 gible entities that have already— 

16 (I) established broad-based col17 laborative partnerships; and 

18 (II) completed environmental as19 sessments. 

20 (ii) NO LEVEL 1 REQUIREMENT.—To 

21 be eligible to receive a grant under this 

22 paragraph, an eligible entity is not re23 quired to have successfully completed a 

24 Level 1 Cooperative Agreement (as de25 scribed in paragraph (2)). 


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1 (B) USE OF GRANT FUNDS.—An eligible 

2 entity awarded a grant under this paragraph 

3 shall use the funds to further activities to carry 

4 out environmental health improvement activi5 ties, including— 

6 (i) addressing community environ7 mental health priorities in accordance with 

8 paragraph (2)(C)(ii), including— 

9 (I) geography; 

10 (II) the built environment; 

11 (III) air quality; 

12 (IV) water quality; 

13 (V) land use; 

14 (VI) solid waste; 

15 (VII) housing; 

16 (VIII) crime; 

17 (IX) socioeconomic status; 

18 (X) ethnicity, social construct 

19 and language preference; 

20 (XI) educational attainment; 

21 (XII) employment; 

22 (XIII) food safety; 

23 (XIV) nutrition; 

24 (XV) health care services; and 

25 (XVI) injuries; 


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1 (ii) building partnerships between 

2 planning, public health, and other sectors, 

3 including child-serving institutions, to ad4 dress how the built environment impacts 

5 food availability and access and physical 

6 activity to promote healthy behaviors and 

7 lifestyles and reduce overweight and obe8 sity, musculoskeletal diseases, respiratory 

9 conditions, dental, oral and mental health 

10 conditions, poverty, and related co11 morbidities; 

12 (iii) establishing programs to ad13 dress— 

14 (I) how environmental and social 

15 conditions of work and living choices 

16 influence physical activity and dietary 

17 intake; or 

18 (II) how those conditions influ19 ence the concerns and needs of people 

20 who have impaired mobility and use 

21 assistance devices, including wheel22 chairs, lower limb prostheses, and hip, 

23 knee, and other joint replacements; 

24 and 


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1 (iv) convening intervention and dem2 onstration programs that examine the role 

3 of the social environment in connection 

4 with the physical and chemical environ5 ment in— 

6 (I) determining access to nutri7 tional food; 

8 (II) improving physical activity to 

9 reduce overweight, obesity, and co10 morbidities and increase quality of 

11 life; and 

12 (III) location and access to med13 ical facilities. 

14 (4) LEVEL 3 COOPERATIVE AGREEMENTS.— 

15 (A) IN GENERAL.—An eligible entity 

16 awarded a grant under this paragraph shall use 

17 the funds to identify and address racial and 

18 ethnic disparities in social determinants of 

19 health by creating demonstration programs that 

20 assess the feasibility of establishing a federally 

21 funded comprehensive program and describe 

22 key outcomes that address racial and ethnic dis23 parities in social determinants of health. 

24 (B) PROGRAM DESIGN.— 


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1 (i) EVALUATION.—No later than 1 

2 year after enactment of this Act, the Di3 rector shall evaluate the best practices of 

4 existing programs from the private, public, 

5 community based, and academically sup6 ported initiatives focused on reducing dis7 parities in the social determinants of 

8 health for racial and ethnic populations. 

9 (ii) DEMONSTRATION PROJECTS.— 

10 Not later than two years after the date of 

11 enactment of this Act, the Director shall 

12 implement at least ten demonstration 

13 projects including at least one project for 

14 each major racial and ethnic minority 

15 group, each of which is unique to the cul16 tural and linguistic needs of each of the 

17 following groups: 

18 (I) Native Americans and Alaska 

19 Natives. 

20 (II) Asian Americans. 

21 (III) African Americans/Blacks. 

22 (IV) Hispanic/Latino-Americans. 

23 (V) Native Hawaiians and Pacific 

24 Islanders. 


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1 (iii) REPORT TO CONGRESS.—No later 

2 than 2 years after the implementation of 

3 the initial demonstration projects, the Di4 rector shall submit to Congress a report 

5 which includes— 

6 (I) a description of each dem7 onstration project and design; 

8 (II) an evaluation of the cost-ef9 fectiveness of each project’s preven10 tion and treatment efforts; 

11 (III) an evaluation of the cultural 

12 and linguistic appropriateness of each 

13 project by racial and ethnic group; 

14 and 

15 (IV) an evaluation of the bene16 ficiary’s health status improvement 

17 under the demonstration project. 

18 (iv) ANY OTHER INFORMATION

19 DEEMED APPROPRIATE BY THE DIREC20 TOR.—The Director shall require any other 

21 information deemed appropriate to be 

22 shared by or developed by eligible entities 

23 awarded a grant under this paragraph, in24 cluding the following: 


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1 (I) Developing models and evalu2 ating methods that improve the cul3 tural and linguistically appropriate 

4 services provided through the Centers 

5 for Disease Control and Prevention to 

6 target individuals impacted by health 

7 disparities based on their race, eth8 nicity, and gender. 

9 (II) Promoting the collaboration 

10 between primary and specialty care 

11 health care providers and patients, to 

12 ensure patients impacted by health 

13 disparities based on race, ethnicity, 

14 and gender are receiving comprehen15 sive and organized treatment and 

16 care. 

17 (III) Educating health care pro18 fessionals on the causes and effects of 

19 disparities in the social determinants 

20 of health as it relates to minority and 

21 racial and ethnic communities and the 

22 need for culturally and linguistically 

23 appropriate care in the prevention and 

24 treatment of high-impact diseases. 


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1 (IV) Encouraging collaboration 

2 among community and patient-based 

3 organizations which work to address 

4 disparities in the social determinants 

5 of health as it relates to high-impact 

6 diseases in minority and racial and 

7 ethnic populations. 

8 (f) AUTHORIZATION OF APPROPRIATIONS.—There 

9 are authorized to be appropriated to carry out this sec10 tion— 

11 (1) $25,000,000 for fiscal year 2019; and 

12 (2) such sums as may be necessary for fiscal 

13 years 2020 through 2022. 

14 SEC. 1006. ADDITIONAL RESEARCH ON THE RELATIONSHIP 

15 BETWEEN THE BUILT ENVIRONMENT AND 

16 THE HEALTH OF COMMUNITY RESIDENTS. 

17 (a) DEFINITION OF ELIGIBLE INSTITUTION.—In this 

18 section, the term ‘‘eligible institution’’ means a public or 

19 private nonprofit institution that submits to the Secretary 

20 of Health and Human Services (in this section referred 

21 to as the ‘‘Secretary’’) and the Administrator of the Envi22 ronmental Protection Agency (in this section referred to 

23 as the ‘‘Administrator’’) an application for a grant under 

24 the grant program authorized under subsection (b)(2) at 

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1 ments, assurances, and information as the Secretary and 

2 Administrator may require. 

3 (b) RESEARCH GRANT PROGRAM.— 

4 (1) DEFINITION OF HEALTH.—In this section, 

5 the term ‘‘health’’ includes— 

6 (A) levels of physical activity; 

7 (B) degree of mobility due to factors such 

8 as musculoskeletal diseases, arthritis, and obe9 sity; 

10 (C) consumption of nutritional foods; 

11 (D) rates of crime; 

12 (E) air, water, and soil quality; 

13 (F) risk of injury; 

14 (G) accessibility to health care services; 

15 (H) levels of educational attainment; and 

16 (I) other indicators as determined appro17 priate by the Secretary. 

18 (2) GRANTS.—The Secretary, in collaboration 

19 with the Administrator, shall provide grants to eligi20 ble institutions to conduct and coordinate research 

21 on the built environment and its influence on indi22 vidual and population-based health. 

23 (3) RESEARCH.—The Secretary shall support 

24 research that— 


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1 (A) investigates and defines the causal 

2 links between all aspects of the built environ3 ment and the health of residents; 

4 (B) examines— 

5 (i) the extent of the impact of the 

6 built environment (including the various 

7 characteristics of the built environment) on 

8 the health of residents; 

9 (ii) the variance in the health of resi10 dents by— 

11 (I) location (such as inner cities, 

12 inner suburbs, and outer suburbs); 

13 and 

14 (II) population subgroup (includ15 ing children, the elderly, the disadvan16 taged); or 

17 (iii) the importance of the built envi18 ronment to the total health of residents, 

19 which is the primary variable of interest 

20 from a public health perspective; 

21 (C) is used to develop— 

22 (i) measures to address health and the 

23 connection of health to the built environ24 ment; and 


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1 (ii) efforts to link the measures to 

2 travel and health databases; 

3 (D) distinguishes carefully between per4 sonal attitudes and choices and external influ5 ences on observed behavior to determine how 

6 much an observed association between the built 

7 environment and the health of residents, versus 

8 the lifestyle preferences of the people that 

9 choose to live in the neighborhood, reflects the 

10 physical characteristics of the neighborhood; 

11 and 

12 (E)(i) identifies or develops effective inter13 vention strategies to promote better health 

14 among residents with a focus on behavioral 

15 interventions and enhancements of the built en16 vironment that promote increased use by resi17 dents; and 

18 (ii) in developing the intervention strate19 gies under clause (i), ensures that the interven20 tion strategies will reach out to high-risk popu21 lations, including racial and ethnic minorities, 

22 low-income urban and rural communities, and 

23 children. 

24 (4) PRIORITY.—In providing assistance under 

25 the grant program authorized under paragraph (2), 


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1 the Secretary and the Administrator shall give pri2 ority to research that incorporates— 

3 (A) minority-serving institutions as grant4 ees; 

5 (B) interdisciplinary approaches; or 

6 (C) the expertise of the public health, 

7 physical activity, nutrition and health care (in8 cluding child health), urban planning, and 

9 transportation research communities in the 

10 United States and abroad. 

11 SEC. 1007. ENVIRONMENT AND PUBLIC HEALTH RESTORA12 TION. 

13 (a) FINDINGS.— 

14 (1) GENERAL FINDINGS.—The Congress finds 

15 as follows: 

16 (A) As human beings, we share our envi17 ronment with a wide variety of habitats and 

18 ecosystems that nurture and sustain a diversity 

19 of species. 

20 (B) The abundance of natural resources in 

21 our environment forms the basis for our econ22 omy and has greatly contributed to human de23 velopment throughout history. 

24 (C) The accelerated pace of human devel25 opment over the last several hundred years has 


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1 significantly impacted our natural environment 

2 and its resources, the health and diversity of 

3 plant and animal wildlife, the availability of 

4 critical habitats, the quality of our air and our 

5 water, and our global climate. 

6 (D) The intervention of the Federal Gov7 ernment is necessary to minimize and mitigate 

8 human impact on the environment for the ben9 efit of public health, to maintain air quality and 

10 water quality, to sustain the diversity of plants 

11 and animals, to combat global climate change, 

12 and to protect the environment. 

13 (E) Laws and regulations in the United 

14 States have been created and promulgated to 

15 minimize and mitigate human impact on the en16 vironment for the benefit of public health, to 

17 maintain air quality and water quality, to sus18 tain wildlife, and to protect the environment. 

19 (F) Such laws include the Antiquities Act 

20 of 1906 (16 U.S.C. 431 et seq.) initiated by 

21 President Theodore Roosevelt to create the na22 tional park system, the National Environmental 

23 Policy Act of 1969 (42 U.S.C. 4321 et seq.), 

24 the Clean Air Act (42 U.S.C. 7401 et seq.), the 

25 Federal Water Pollution Control Act (33 U.S.C. 


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1 1251 et seq.), the Comprehensive Environ2 mental Response, Compensation, and Liability 

3 Act of 1980 (42 U.S.C. 9601 et seq.), the En4 dangered Species Act of 1973 (Public Law 93– 

5 205), and the National Forest Management Act 

6 of 1976 (Public Law 94–588). 

7 (G) Attempts to repeal or weaken key envi8 ronmental safeguards pose dangers to the pub9 lic health, air quality, water quality, wildlife, 

10 and the environment. 

11 (2) FINDINGS ON CHANGES AND PROPOSED

12 CHANGES IN LAW.—The Congress finds that, since 

13 2001, the following changes and proposed changes 

14 to existing law or regulations have negatively im15 pacted or will negatively impact the environment and 

16 public health: 

17 (A) CLEAN WATER.— 

18 (i) On May 9, 2002, the Environ19 mental Protection Agency (EPA) and the 

20 Army Corps of Engineers put forth a final 

21 rule that reconciled regulations imple22 menting section 404 of the Federal Water 

23 Pollution Control Act by redefining the 

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1 rial’’, reversing a 25-year-old regulation. 

2 The new rule fails to restrict the dumping 

3 of hardrock mining waste, construction de4 bris, and other industrial wastes into riv5 ers, streams, lakes, and wetlands. The rule 

6 further allows destructive mountaintop re7 moval coal mining companies to dump 

8 waste into streams and lakes, polluting the 

9 surrounding natural habitat and poisoning 

10 plants and animals that depend on those 

11 water sources. 

12 (ii) On February 12, 2003, the Envi13 ronmental Protection Agency published the 

14 rule ‘‘National Pollutant Discharge Elimi15 nation System Permit Regulation and Ef16 fluent Limitation Guidelines and Stand17 ards for Concentrated Animal Feeding Op18 erations’’, new livestock waste regulations 

19 that aimed to control factory farm pollu20 tion but which would severely undermine 

21 existing protections under the Federal 

22 Water Pollution Control Act. This regula23 tion allows large-scale animal factories to 

24 foul the Nation’s waters with animal 

25 waste, allows livestock owners to draft 


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1 their own pollution-management plans and 

2 avoid ground water monitoring, legalizes 

3 the discharge of contaminated runoff water 

4 rich in nitrogen, phosphorus, bacteria, and 

5 metals, and ensures that large factory 

6 farms are not held liable for the environ7 mental damage they cause. In a 2005 Fed8 eral court decision (‘‘Waterkeeper Alliance, 

9 et al. v. Environmental Protection Agen10 cy’’, 399 F.3d 486 (2nd Cir. 2005)), major 

11 parts of the rule were upheld, others va12 cated, and still others remanded back to 

13 the EPA. On November 20, 2008, the En14 vironmental Protection Agency published a 

15 revised final rule which undermines envi16 ronmental protection provisions by remov17 ing mandatory permitting requirements 

18 and allowing large animal farms to self19 certify the absence of pollutant discharge 

20 activity. 

21 (iii) On March 19, 2003, the Environ22 mental Protection Agency published a new 

23 rule regarding the Total Maximum Daily 

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1 imum amount of a particular pollutant 

2 that can be present in a body of water and 

3 still meet water quality standards. The new 

4 rule withdrew the existing regulation put 

5 forth on July 13, 2000, and halted mo6 mentum in cleaning up polluted waterways 

7 throughout the Nation. By abandoning the 

8 existing rule, the Environmental Protection 

9 Agency is undermining the effectiveness of 

10 cleanup plans and is allowing States to 

11 avoid cleaning polluted waters entirely by 

12 dropping them from their cleanup lists. 

13 Waterways play a crucial role in the lives 

14 of the people of the United States and are 

15 critical to the livelihood of fish and wildlife. 

16 The result of dropping the July 2000 rule 

17 is that the restoration of polluted rivers, 

18 shorelines, and lakes will be delayed, harm19 ing more fish and wildlife and worsening 

20 the quality of drinking water. 

21 (iv) On December 2, 2008, the Envi22 ronmental Protection Agency and the 

23 Army Corps of Engineers jointly issued a 

24 guidance document in the form of a legal 

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1 risdiction Following the U.S. Supreme 

2 Court’s Decision in Rapanos v. United 

3 States & Carabell v. United States’’. This 

4 new guidance dictates enforcement actions 

5 under the Federal Water Pollution Control 

6 Act and calls for a complicated ‘‘case-by7 case’’ analysis to determine jurisdiction for 

8 waterways that do not flow all year. Such 

9 actions endanger small streams and wet10 lands that serve as important habitats for 

11 aquatic life, which play a fundamental role 

12 in safeguarding sources of clean drinking 

13 water and mitigate the risks and effects of 

14 floods and droughts. Further, the defini15 tion provided therein for ‘‘waters of the 

16 United States’’ is applicable to the Federal 

17 Water Pollution Control Act as a whole, 

18 potentially affecting programs that control 

19 industrial pollution and sewage levels, pre20 vent oil spills, and set water quality stand21 ards for all waters in the United States 

22 protected under the Federal Water Pollu23 tion Control Act. 

24 (B) FORESTS AND LAND MANAGEMENT.— 


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1 (i) On December 3, 2003, the Presi2 dent signed into law the Healthy Forests 

3 Restoration Act of 2003 (Public Law 108– 

4 148; 16 U.S.C. 6501 et seq.). Although the 

5 law attempts to reduce the risk of cata6 strophic forest fires, it provides a boon to 

7 timber companies by accelerating the ag8 gressive thinning of backcountry forests 

9 that are far from at-risk communities. The 

10 law allows for increased logging of large, 

11 fire-resistant trees that are not in close 

12 proximity of homes and communities; it 

13 undermines critical protections for endan14 gered species by exempting Federal land 

15 management agencies from consulting with 

16 the United States Fish and Wildlife Serv17 ice before approving any action that could 

18 harm endangered plants or wildlife; and it 

19 limits public participation by reducing the 

20 number of environmental project reviews. 

21 (ii) On April 21, 2008, the Depart22 ment of Agriculture issued a Final Plan23 ning Rule and Record of Decision for Na24 tional Forest System Land Management 

25 Planning. Similar to rules enacted by the 


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1 Administration on January 5, 2005, later 

2 remanded back to the agency in Federal 

3 district court for violating the National 

4 Environmental Policy Act of 1969, the En5 dangered Species Act of 1973, and the Ad6 ministrative Procedure Act (‘‘Citizens for 

7 Better Forestry v. United States Depart8 ment of Agriculture’’, 481 F. Supp. 2d 

9 1059 (N.D. Cal. 2007)), this revised rule 

10 eliminates strict forest planning standards 

11 established in 1982, and opens millions of 

12 acres of public lands to damaging and 

13 invasive logging, mining, and drilling oper14 ations. These regulations would reverse 

15 more than 20 years of protection for wild16 life and national forests by removing the 

17 overall goal of ensuring ecological sustain18 ability in managing the national forest sys19 tem, weakening the National Forest Man20 agement Act of 1976, and effectively end21 ing the review of forest management plans 

22 under the National Environmental Policy 

23 Act of 1969. 

24 (iii) On September 20, 2006, the Dis25 trict Court for the Northern District of 


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1 California vacated the Protection of Inven2 toried Roadless Areas rule, enacted on May 

3 13, 2005, which gave State Governors 18 

4 months to petition the Federal Government 

5 to either restore the previous rule for their 

6 States, or submit a new management and 

7 development plan for national forest areas 

8 inventoried under the rule. Despite the 

9 enjoinment of the Administration’s 2005 

10 rule, and the subsequent restoration of the 

11 original Roadless Area Conservation Rule, 

12 the United States Forest Service has con13 tinued to allow States to petition for a spe14 cial rule under the authority of the Admin15 istrative Procedure Act, publishing a final 

16 special rule for Idaho on October 16, 2008. 

17 As a result, 58.5 million acres of wild na18 tional forests are still vulnerable to log19 ging, road building, and other develop20 ments that may fragment natural habitats 

21 and negatively impact fish and wildlife. 

22 (iv) On November 17, 2008, the De23 partment of the Interior’s Bureau of Land 

24 Management (BLM) signed the Record of 

25 Decision (ROD) amending 12 resource 


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1 management plans in Colorado, Utah, and 

2 Wyoming, opening 2,000,000 acres of pub3 lic lands to commercial tar sands and oil 

4 shale exploration and development. On No5 vember 18, 2008, the BLM published a 

6 final rule for Oil Shale Management set7 ting the policies and procedures for a com8 mercial leasing program for the manage9 ment of federally owned oil shale in those 

10 three States. Previously barred by a con11 gressional moratorium on the commercial 

12 leasing regulations for oil shale until Sep13 tember 30, 2008, the development of oil 

14 shale on public lands poses a serious threat 

15 to land conservation, endangered and 

16 threatened species, and critical habitat. 

17 Domestic shale oil production allowed by 

18 these regulations is highly water and en19 ergy intensive, the impacts of which will in20 tensify existing water scarcity in the arid 

21 Western Region and potentially degrade 

22 air and water quality for surrounding pop23 ulations. 

24 (C) SCIENTIFIC REVIEW.—On December 

25 16, 2008, the United States Fish and Wildlife 


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1 Service of the Department of the Interior and 

2 the National Oceanic and Atmospheric Admin3 istration of the Department of Commerce joint4 ly issued a new rule amending regulations gov5 erning interagency cooperation under section 7 

6 of the Endangered Species Act of 1973 (ESA). 

7 This rule undermines the intention of the ESA 

8 to protect species and the ecosystems upon 

9 which they depend by allowing Federal agencies 

10 to carry out, permit, or fund an action without 

11 proper environmental review and expert third12 party consultation from Federal wildlife ex13 perts. Under this new rule, Federal agencies 

14 can unilaterally circumvent the formal review 

15 process, eliminating longstanding and scientif16 ically grounded safeguards that serve to protect 

17 the biodiversity of our Nation’s ecosystems and 

18 avert harm to thousands of endangered and 

19 threatened species. 

20 (b) STATEMENT OF POLICY.—It is the policy of the 

21 United States Government to work in conjunction with 

22 States, territories, Tribal governments, international orga23 nizations, and foreign governments in order to act as a 

24 steward of the environment for the benefit of public 

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1 tain the diversity of plant and animal species, to combat 

2 global climate change, and to protect the environment for 

3 future generations to enjoy. 

4 (c) STUDY AND REPORT ON PUBLIC HEALTH OR EN5 VIRONMENTAL IMPACT OF REVISED RULES, REGULA6 TIONS, LAWS, OR PROPOSED LAWS.— 

7 (1) STUDY.—Not later than 30 days after the 

8 date of enactment of this Act, the President shall 

9 enter into an arrangement under which the National 

10 Academy of Sciences will conduct a study to deter11 mine the impact on public health, air quality, water 

12 quality, wildlife, and the environment of the fol13 lowing regulations, laws, and proposed laws: 

14 (A) CLEAN WATER.— 

15 (i) Final revisions to the Federal 

16 Water Pollution Control Act regulatory 

17 definitions of ‘‘fill material’’ and ‘‘dis18 charge of fill material’’, finalized and pub19 lished in the Federal Register on May 9, 

20 2002 (67 Fed. Reg. 31129), amending 

21 part 232 of title 40, Code of Federal Regu22 lations. 

23 (ii) Revised National Pollutant Dis24 charge Elimination System Permit Regula25 tion and Effluent Limitation Guidelines 


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1 and Standards for Concentrated Animal 

2 Feeding Operations in response to the 

3 ‘‘Waterkeeper Alliance, et al. v. Environ4 mental Protection Agency’’ decision, final5 ized and published in the Federal Register 

6 on November 20, 2008 (73 Fed. Reg. 

7 225), amending parts 9, 122, and 412 of 

8 title 40, Code of Federal Regulations. 

9 (iii) A March 19, 2003, rule published 

10 in the Federal Register (68 Fed. Reg. 

11 13608) withdrawing a July 13, 2000, rule 

12 revising the Total Maximum Daily Load 

13 program of the Federal Water Pollution 

14 Control Act (65 Fed. Reg. 43586), amend15 ing parts 9, 122, 123, 124, and 130 of 

16 title 40, Code of Federal Regulations. 

17 (iv) Official Guidance Document, 

18 ‘‘Clean Water Act Jurisdiction Following 

19 the United States Supreme Court’s Deci20 sion in Rapanos v. United States & 

21 Carabell v. United States’’, issued on De22 cember 2, 2008, relating to jurisdiction 

23 under section 404 of the Federal Water 

24 Pollution Control Act. 

25 (B) FORESTS AND LAND MANAGEMENT.— 


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1 (i) Healthy Forests Restoration Act of 

2 2003, signed into law on December 3, 

3 2003 (Public Law 108–148; 16 U.S.C. 

4 6501 et seq.). 

5 (ii) National Forest System Land 

6 Management Planning Rule, finalized and 

7 published in the Federal Register on April 

8 21, 2008 (73 Fed. Reg. 21468), replacing 

9 the 2005 final rule (70 Fed. Reg. 1022, 

10 Jan. 5, 2005), as amended March 3, 2006 

11 (71 Fed. Reg. 10837), and the 2000 final 

12 rule adopted on November 9, 2000 (65 

13 Fed. Reg. 67514), as amended on Sep14 tember 29, 2004 (69 Fed. Reg. 58055), 

15 amending title 36, Code of Federal Regula16 tions, part 219. 

17 (iii) The application of the Adminis18 trative Procedure Act (5 U.S.C. 551 to 

19 559, 701 to 706, et seq.), such that States 

20 may petition for a special rule for the 

21 roadless areas in all or part of said State. 

22 (iv) Record of Decision, ‘‘Oil Shale 

23 and Tar Sands Resources Resource Man24 agement Plan Amendments’’, issued on 

25 November 17, 2008, along with the Final 


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1 Rule, Oil Shale Management-General, pub2 lished in the Federal Register on Novem3 ber 18, 2008 (73 Fed. Reg. 223), amend4 ing title 43, Code of Federal Regulations, 

5 parts 3900, 3910, 3920, and 3930. 

6 (C) SCIENTIFIC REVIEW.—Final Rule, 

7 Interagency Cooperation Under the Endangered 

8 Species Act, published in the Federal Register 

9 on December 16, 2008, amending title 50, Code 

10 of Federal Regulations, part 402. 

11 (2) METHOD.—In conducting the study under 

12 paragraph (1), the National Academy of Sciences 

13 may utilize and compare existing scientific studies 

14 regarding the regulations, laws, and proposed laws 

15 listed in paragraph (1). 

16 (3) REPORT.—Under the arrangement entered 

17 into under paragraph (1), not later than 270 days 

18 after the date on which such arrangement is entered 

19 into, the National Academy of Sciences shall make 

20 publicly available and shall submit to the Congress 

21 and to the head of each department and agency of 

22 the Federal Government that issued, implements, or 

23 would implement a regulation, law, or proposed law 

24 listed in paragraph (1), a report containing— 


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1 (A) a description of the impact of all such 

2 regulations, laws, and proposed laws on public 

3 health, air quality, water quality, wildlife, and 

4 the environment, compared to the impact of 

5 preexisting regulations, or laws in effect, includ6 ing— 

7 (i) any negative impacts to air quality 

8 or water quality; 

9 (ii) any negative impacts to wildlife; 

10 (iii) any delays in hazardous waste 

11 cleanup that are projected to be hazardous 

12 to public health; and 

13 (iv) any other negative impact on pub14 lic health or the environment; and 

15 (B) any recommendations that the Na16 tional Academy of Sciences considers appro17 priate to maintain, restore, or improve in whole 

18 or in part protections for public health, air 

19 quality, water quality, wildlife, and the environ20 ment for each of the regulations, laws, and pro21 posed laws listed in paragraph (1), which may 

22 include recommendations for the adoption of 

23 any regulation or law in place or proposed prior 

24 to January 1, 2001. 


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1 (d) DEPARTMENT AND AGENCY REVISION OF EXIST2 ING RULES, REGULATIONS, OR LAWS.—Not later than 

3 180 days after the date on which the report is submitted 

4 pursuant to subsection (c)(3), the head of each depart5 ment and agency that has issued or implemented a regula6 tion or law listed in subsection (c)(1) shall submit to the 

7 Congress a plan describing the steps such department or 

8 such agency will take, or has taken, to restore or improve 

9 protections for public health and the environment in whole 

10 or in part that were in existence prior to the issuance of 

11 such regulation or law. 

12 SEC. 1008. GAO REPORT ON HEALTH EFFECTS OF DEEP13 WATER HORIZON OIL RIG EXPLOSION IN THE 

14 GULF COAST. 

15 (a) STUDY.—The Comptroller General of the United 

16 States shall conduct a study on the type and scope of 

17 health care services administered through the Department 

18 of Health and Human Services addressing the provision 

19 of health care to racial and ethnic minorities, including 

20 residents, cleanup workers, and volunteers, affected by the 

21 explosion of the mobile offshore drilling unit Deepwater 

22 Horizon that occurred on April 20, 2010. 

23 (b) SPECIFIC COMPONENTS; REPORTING.—In car24 rying out subsection (a), the Comptroller General shall— 


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1 (1) assess the type, size, and scope of programs 

2 administered by the Department of Health and 

3 Human Services that focus on provision of health 

4 care to communities in the Gulf Coast; 

5 (2) identify the merits and disadvantages asso6 ciated with each the programs; 

7 (3) perform an analysis of the costs and bene8 fits of the programs; 

9 (4) determine whether there is any duplication 

10 of programs; and 

11 (5) not later than 180 days after the date of 

12 the enactment of this Act, submit to Congress a re13 port containing— 

14 (A) the findings of the study conducted 

15 under this section; and 

16 (B) recommendations for improving access 

17 to health care for racial and ethnic minorities. 

18 Subtitle B—Gun Violence 

19 SEC. 1011. FINDINGS. 

20 Congress finds as follows: 

21 (1) On average, 86 Americans are killed by 

22 guns each day. 

23 (2) An estimated 15,549 people were killed by 

24 guns in 2017, not including suicides. 


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1 (3) Gun violence disproportionately affects com2 munities of color, especially African Americans (who 

3 comprise around 14 percent of the United States 

4 population but account for more than half the coun5 try’s gun homicide victims). 

6 (4) On average, there is more than one mass 

7 shooting each day in the United States. 

8 SEC. 1012. REAFFIRMING RESEARCH AUTHORITY OF THE 

9 CENTERS FOR DISEASE CONTROL AND PRE10 VENTION. 

11 (a) IN GENERAL.—Section 391 of the Public Health 

12 Service Act (42 U.S.C. 280b) is amended— 

13 (1) in subsection (a)(1), by striking ‘‘research 

14 relating to the causes, mechanisms, prevention, diag15 nosis, treatment of injuries, and rehabilitation from 

16 injuries;’’ and inserting ‘‘research, including data 

17 collection, relating to— 

18 ‘‘(A) the causes, mechanisms, prevention, 

19 diagnosis, and treatment of injuries, including 

20 with respect to gun violence; and 

21 ‘‘(B) rehabilitation from such injuries;’’; 

22 and 

23 (2) by adding at the end the following new sub24 section: 


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1 ‘‘(c) NO ADVOCACY OR PROMOTION OF GUN CON2 TROL.—Nothing in this section shall be construed to— 

3 ‘‘(1) authorize the Secretary to give assistance, 

4 make grants, or enter into cooperative agreements or 

5 contracts for the purpose of advocating or promoting 

6 gun control; or 

7 ‘‘(2) permit a recipient of any assistance, grant, 

8 cooperative agreement, or contract under this section 

9 to use such assistance, grant, agreement, or contract 

10 for the purpose of advocating or promoting gun con11 trol.’’. 

12 SEC. 1013. NATIONAL VIOLENT DEATH REPORTING SYSTEM. 

13 The Secretary of Health and Human Services, acting 

14 through the Director of the Centers for Disease Control 

15 and Prevention, shall improve, particularly through the in16 clusion of additional States, the National Violent Death 

17 Reporting System, as authorized by title III of the Public 

18 Health Service Act (42 U.S.C. 241 et seq.). Participation 

19 in the system by the States shall be voluntary. 

20 SEC. 1014. REPORT ON EFFECTS OF GUN VIOLENCE ON 

21 PUBLIC HEALTH. 

22 Not later than one year after the date of the enact23 ment of this Act, and annually thereafter, the Surgeon 

24 General of the Public Health Service shall submit to Con25 gress a report on the effects on public health, including 


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1 mental health, of gun violence in the United States during 

2 the preceding year, and the status of actions taken to ad3 dress such effects. 

4 SEC. 1015. REPORT ON EFFECTS OF GUN VIOLENCE ON 

5 MENTAL HEALTH IN MINORITY COMMU6 NITIES. 

7 Not later than one year after the date of the enact8 ment of this Act, the Deputy Assistant Secretary for Mi9 nority Health in the Office of the Secretary of Health and 

10 Human Services shall submit to the Congress a report on 

11 the effects of gun violence on public health, including men12 tal health, in minority communities in the United States, 

13 and the status of actions taken to address such effects. 

Æ 


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