II 

113TH CONGRESS 

2D SESSION S. 2229 

To expand primary care access. 

IN THE SENATE OF THE UNITED STATES 

APRIL 9, 2014 

Mr. SANDERS introduced the following bill; which was read twice and referred 

to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To expand primary care access. 

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 ‘‘Expanding Primary 

5 Care Access and Workforce Act’’. 

6 SEC. 2. SCHOLARSHIPS AND LOAN REPAYMENT OPPORTU7 NITIES FOR PRIMARY CARE PROVIDERS. 

8 (a) FUNDING FOR THE NATIONAL HEALTH SERVICE

9 CORPS.—Section 338 of the Public Health Service Act (42 

10 U.S.C. 254k) is amended by adding at the end the fol11 lowing: 


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1 ‘‘(c) SCHOLARSHIP AND LOAN REPAYMENT OPPOR2 TUNITIES FOR PRIMARY CARE PROVIDERS.— 

3 ‘‘(1) IN GENERAL.—There is authorized to be 

4 appropriated, and there is appropriated, out of any 

5 amounts in the Treasury not otherwise appropriated, 

6 $4,900,000,000 for the period of fiscal years 2015 

7 through 2020, to provide for a continuation and ex8 pansion of the program with respect to required pri9 mary health services, as defined in section 330(b), 

10 under this subpart. 

11 ‘‘(2) SUPPLEMENTAL FUNDING.—Amounts ap12 propriated under this subsection shall be used to 

13 supplement and not supplant other amounts appro14 priated to carry out programs under this subpart.’’. 

15 (b) SCHOLARSHIP PROGRAM AND STUDENT LOAN

16 REPAYMENT PROGRAM.—Section 338H of the Public 

17 Health Service Act (42 U.S.C. 254q) is amended by add18 ing at the end the following: 

19 ‘‘(d) DISTRIBUTION OF FUNDS.—In allocating funds 

20 made available to the Health Resources and Services Ad21 ministration for the National Health Service Corps, the 

22 Secretary shall provide loan repayment awards to at least 

23 6 individuals in each State and scholarships to at least 

24 3 individuals in each State.’’. 


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1 (c) PUBLIC INFORMATION PROGRAMS IN DES2 IGNATED AREAS.—Section 332(h) of the Public Health 

3 Service Act (42 U.S.C. 254e(h)) is amended by inserting 

4 ‘‘(directly, or by grant, contract, or cooperative agree5 ment)’’ after ‘‘conduct’’. 

6 (d) PROFESSIONAL DEVELOPMENT.—Section 

7 336(d)(1) of the Public Health Service Act (42 U.S.C. 

8 254h–1(d)(1)) is amended by inserting ‘‘(directly, or by 

9 grant, contract, or cooperative agreement)’’ after ‘‘shall 

10 assist’’. 

11 SEC. 3. FUNDING FOR HEALTH CENTERS. 

12 Section 10503(b)(1) of the Patient Protection and 

13 Affordable Care Act of 2010 (42 U.S.C. 254b–2) is 

14 amended— 

15 (1) in subparagraph (D), by striking ‘‘and’’ at 

16 the end; 

17 (2) in subparagraph (E), by striking ‘‘and’’ at 

18 the end; and 

19 (3) by inserting after subparagraph (E) the fol20 lowing: 

21 ‘‘(F) $3,800,000,000 for fiscal year 2016; 

22 ‘‘(G) $4,300,000,000 for fiscal year 2017; 

23 ‘‘(H) $4,900,000,000 for fiscal year 2018; 

24 ‘‘(I) $5,600,000,000 for fiscal year 2019; 

25 and 


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1 ‘‘(J) $6,400,000,000 for fiscal year 2020; 

2 and’’. 

3 SEC. 4. INCREASING THE PRIMARY CARE PROVIDER WORK4 FORCE. 

5 (a) REAUTHORIZATION OF THE TEACHING HEALTH

6 CENTERS PROGRAM.—Section 340H of the Public Health 

7 Service Act (42 U.S.C. 256h) is amended— 

8 (1) in subsection (a), by striking ‘‘subsection 

9 (h)(2)’’ and inserting ‘‘subsection (i)(2)’’; 

10 (2) in subsection (g)— 

11 (A) by striking ‘‘such sums’’ and all that 

12 follows through the period at the end and in13 serting ‘‘$800,000,000 for the period of fiscal 

14 years 2016 through 2020.’’; and 

15 (B) by adding at the end the following: 

16 ‘‘Any amounts appropriated under this sub17 section for any of fiscal years 2011 through 

18 2020 and remaining unexpended at the end of 

19 the fiscal year involved may be used in subse20 quent fiscal years to carry out this section.’’; 

21 (3) in subsection (h)(2)— 

22 (A) in the paragraph heading, by adding at 

23 the end the following: ‘‘; SUBMISSION TO CON24 GRESS’’; and 

25 (B) by adding at the end the following: 


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1 ‘‘(C) SUBMISSION TO CONGRESS.—The 

2 Secretary shall annually submit to Congress a 

3 report that contains a compilation of the data 

4 submitted to the Secretary under paragraph (1) 

5 for the year involved.’’; 

6 (4) by redesignating subsections (h) through (j) 

7 as subsections (i) through (k), respectively; and 

8 (5) by inserting after subsection (g), the fol9 lowing: 

10 ‘‘(h) LIMITATION.—The Secretary shall establish a 

11 minimum per resident per year payment amount for fund12 ing of all approved teaching health center graduate med13 ical education positions under this section that shall be 

14 not less than the per resident per year payment amount 

15 as of January 1, 2013, and ensure that not less than such 

16 amount is provided to all teaching health center graduate 

17 medical education programs for all approved positions.’’. 

18 (b) TEACHING HEALTH CENTERS DEVELOPMENT

19 GRANTS.—Section 749A(g) of the Public Health Service 

20 Act (42 U.S.C. 293l–1(g)) is amended by striking ‘‘each 

21 fiscal year thereafter’’ and inserting ‘‘each of fiscal years 

22 2013 through 2020 and each fiscal year thereafter’’. 

23 (c) NATIONAL HEALTH CARE WORKFORCE COMMIS24 SION.—Section 5101 of the Patient Protection and Afford25 able Care Act (42 U.S.C. 294q) is amended— 


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1 (1) in subsection (h)— 

2 (A) by striking paragraphs (1) and (2) and 

3 inserting the following: 

4 ‘‘(1) APPROPRIATIONS.—There are authorized 

5 to be appropriated, and there are appropriated, out 

6 of any monies in the Treasury not otherwise appro7 priated, $10,000,000 for each fiscal year to carry 

8 out this section.’’; and 

9 (B) by redesignating paragraph (3) as 

10 paragraph (2); and 

11 (2) in subsection (d)— 

12 (A) in paragraph (7), by adding at the end 

13 ‘‘Whenever feasible, Congress and the Depart14 ment of Health and Human Services shall rec15 ognize and implement such recommendations.’’; 

16 and 

17 (B) by adding at the end the following: 

18 ‘‘(9) DATA TRACKING.— 

19 ‘‘(A) DATA TRACKING MECHANISM.—The 

20 Commission shall develop, or enter into a con21 tract with another entity to develop, a mecha22 nism for tracking information on the career 

23 paths of graduates of medical schools and resi24 dency programs, as described in subparagraph 


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1 (B), and shall make such information publicly 

2 available. 

3 ‘‘(B) RECORDKEEPING.—The Commission 

4 shall collect or ensure the collection of data, 

5 using the mechanism developed under subpara6 graph (A), concerning— 

7 ‘‘(i) the specialty and subspecialty 

8 training of all graduates of medical schools 

9 receiving Federal funding; and 

10 ‘‘(ii) the professional trajectory of all 

11 graduates of medical schools receiving Fed12 eral funding for not less than 15 years 

13 after each individual graduates from med14 ical school, including data concerning grad15 uates who practice medicine— 

16 ‘‘(I) in underserved areas such as 

17 health professional shortage areas (as 

18 defined by the National Health Serv19 ice Corps under section 332 of the 

20 Public Health Service Act (42 U.S.C. 

21 254e)); 

22 ‘‘(II) with medically underserved 

23 populations (as defined in section 

24 330(b)(3) of the Public Health Serv25 ice Act (42 U.S.C. 254b(b)(3))); 


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1 ‘‘(III) in Federally qualified 

2 health centers (as defined in section 

3 1905(l)(2)(B) of the Social Security 

4 Act (42 U.S.C. 1396d(l)(2)(B))); 

5 ‘‘(IV) rural health clinics (under 

6 title XVIII of the Social Security Act 

7 (42 U.S.C. 1395 et seq.)); 

8 ‘‘(V) the health care system of 

9 the Department of Veterans Affairs; 

10 and 

11 ‘‘(VI) clinics of the Indian Health 

12 Services.’’. 

13 (d) REAUTHORIZATION OF FAMILY NURSE PRACTI14 TIONER RESIDENCY TRAINING PROGRAM.—Section 

15 5316(i) of the Patient Protection and Affordable Care Act 

16 (42 U.S.C. 296j–1(i)) is amended by striking ‘‘such sums’’ 

17 and all that follows through the period at the end and 

18 inserting ‘‘$75,000,000 for the period of fiscal years 2015 

19 through 2019.’’. 

20 (e) REAUTHORIZATION OF NURSE FACULTY LOAN

21 PROGRAM.—Section 846A(f) of the Public Health Service 

22 Act (42 U.S.C. 297n–1(f)) is amended by striking ‘‘2014’’ 

23 and inserting ‘‘2019’’. 

24 (f) REAUTHORIZATION OF PRIMARY CARE RESI25 DENCY EXPANSION PROGRAM.—Section 747(c)(1) of the 


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1 Public Health Service Act (42 U.S.C. 293k(c)(1)) is 

2 amended by striking ‘‘$125,000,000’’ and all that follows 

3 through the period at the end and inserting 

4 ‘‘$168,000,000 for the period of fiscal years 2015 through 

5 2019.’’. 

6 (g) REAUTHORIZATION OF THE AREA HEALTH EDU7 CATION CENTERS.—Section 751(j)(1) of the Public 

8 Health Service Act (42 U.S.C. 294a(j)(1)) is amended by 

9 striking ‘‘2010 through 2014’’ and inserting ‘‘2015 

10 through 2019’’. 

11 SEC. 5. INCREASING PAYMENT FOR PRIMARY CARE. 

12 (a) REQUIREMENT CONCERNING CONSULTATION

13 WITH ORGANIZATIONS OR OTHER ENTITIES.—In deter14 mining physician fees for the purpose of payments under 

15 the Medicare program under title XVIII of the Social Se16 curity Act (42 U.S.C. 1395 et seq.), the Secretary of 

17 Health and Human Services shall not consult with an or18 ganization or other entity representing physicians unless 

19 at least 50 percent of the members of such organization 

20 or entity, at the time of such consultation, are primary 

21 care physicians. 

22 (b) INCENTIVE PAYMENT PROGRAM FOR PRIMARY

23 CARE SERVICES.—Section 1833(x)(1) of the Social Secu24 rity Act (42 U.S.C. 1395l(x)(1)) is amended by striking 

25 ‘‘2016’’ and inserting ‘‘2020’’. 


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1 (c) PERMANENT APPLICATION OF MEDICARE PAY2 MENT RATE FLOOR TO PRIMARY CARE SERVICES FUR3 NISHED UNDER MEDICAID.— 

4 (1) IN GENERAL.—Section 1902(a)(13)(C) of 

5 the Social Security Act (42 U.S.C. 1396a(a)(13)(C)) 

6 is amended by striking ‘‘and 2014’’ and inserting 

7 ‘‘or any year thereafter’’. 

8 (2) INCREASED FMAP.—Section 1905(dd) of 

9 the Social Security Act (42 U.S.C. 1396d(dd)) is 

10 amended by striking ‘‘and before January 1, 2015,’’. 

11 (3) EFFECTIVE DATE.—The amendments made 

12 by this subsection take effect on January 1, 2015. 

13 SEC. 6. ACCOUNTABILITY FOR FEDERAL FUNDS AT MED14 ICAL SCHOOLS. 

15 (a) FAMILY MEDICINE OR PRIMARY CARE DEPART16 MENT.—A medical school that receives Federal funds for 

17 any purpose shall— 

18 (1) maintain in such medical school a family 

19 medicine or primary care department; and 

20 (2) require for all students at least 8 weeks of 

21 rotations in family medicine or community-oriented 

22 primary care during the third year of training. 

23 (b) REPORTING ON MEETING HEALTH CARE WORK24 FORCE NEEDS.—A medical school that receives Federal 

25 funds for any purpose shall— 


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1 (1) prepare an annual report— 

2 (A) responding to the data with respect to 

3 such medical school that is collected under sec4 tion 5101(d)(9) of the Patient Protection and 

5 Affordable Care Act (as added by section 

6 4(c)(2)(B)); and 

7 (B) detailing the actions the medical school 

8 is taking to meet the health care workforce 

9 needs in the school’s community and across the 

10 Nation; and 

11 (2) submit such report to the Secretary of 

12 Health and Human Services and the National 

13 Health Care Workforce Commission. 

14 SEC. 7. INCREASING OPPORTUNITIES AND ACCOUNT15 ABILITY FOR PRIMARY CARE RESIDENCY 

16 TRAINING. 

17 (a) ADDITIONAL RESIDENCY POSITIONS FOR TRAIN18 ING IN FAMILY MEDICINE.— 

19 (1) IN GENERAL.—Section 1886(h) of the So20 cial Security Act (42 U.S.C. 1395ww(h)) is amend21 ed— 

22 (A) in paragraph (4)(F)(i), by striking 

23 ‘‘paragraphs (7) and (8)’’ and inserting ‘‘para24 graphs (7), (8), and (9)’’; 


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1 (B) in paragraph (4)(H)(i), by striking 

2 ‘‘paragraphs (7) and (8)’’ and inserting ‘‘para3 graphs (7), (8), and (9)’’; 

4 (C) in paragraph (7)(E), by inserting 

5 ‘‘paragraph (9),’’ after ‘‘paragraph (8),’’; and 

6 (D) by adding at the end the following new 

7 paragraph: 

8 ‘‘(9) ADDITIONAL RESIDENCY POSITIONS FOR

9 TRAINING IN FAMILY MEDICINE.— 

10 ‘‘(A) IN GENERAL.— 

11 ‘‘(i) DISTRIBUTION.—For fiscal year 

12 2014 (and succeeding fiscal years if the 

13 Secretary determines that there are addi14 tional residency positions available to dis15 tribute under subparagraph (D)), the Sec16 retary shall increase the otherwise applica17 ble resident limit for each qualifying hos18 pital that submits a timely application 

19 under this subparagraph by such number 

20 as the Secretary may approve for portions 

21 of cost reporting periods occurring on or 

22 after July 1 of the fiscal year of the in23 crease. Such additional residency positions 

24 shall be for approved medical residency 


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1 training programs (as defined in para2 graph (5)(A)) in family medicine. 

3 ‘‘(ii) REQUIREMENTS.—Subject to 

4 clause (iii), a hospital that receives an in5 crease in the otherwise applicable resident 

6 limit under this paragraph shall ensure, 

7 during the 5-year period beginning on the 

8 date of such increase, that— 

9 ‘‘(I) the number of full-time 

10 equivalent residents in family medi11 cine (as determined by the Secretary), 

12 excluding any additional positions 

13 under subclause (II), is not less than 

14 the average number of full-time equiv15 alent residents in family medicine (as 

16 so determined) during the 3 most re17 cent cost reporting periods ending 

18 prior to the date of enactment of this 

19 paragraph; and 

20 ‘‘(II) 100 percent of the positions 

21 attributable to such increase are in an 

22 approved medical residency training 

23 program in family medicine (as deter24 mined by the Secretary). 


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1 ‘‘(iii) REDISTRIBUTION OF POSITIONS

2 IF HOSPITAL NO LONGER MEETS CERTAIN

3 REQUIREMENTS.—In the case where the 

4 Secretary determines that a hospital de5 scribed in clause (ii) does not meet either 

6 of the requirements under subclause (I) or 

7 (II) of such clause, the Secretary shall— 

8 ‘‘(I) reduce the otherwise applica9 ble resident limit of the hospital by 

10 the amount by which such limit was 

11 increased under this paragraph; and 

12 ‘‘(II) provide for the distribution 

13 of positions attributable to such re14 duction in accordance with the re15 quirements of this paragraph. 

16 ‘‘(B) AGGREGATE NUMBER OF IN17 CREASES.—The aggregate number of increases 

18 in the otherwise applicable resident limit under 

19 this paragraph shall be equal to 2,000. 

20 ‘‘(C) TIMING.—The Secretary shall notify 

21 hospitals of the number of positions distributed 

22 to the hospital under this paragraph as result 

23 of an increase in the otherwise applicable resi24 dent limit by January 1 of the fiscal year of the 

25 increase. Such increase shall be effective for 


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1 portions of cost reporting periods beginning on 

2 or after July 1 of that fiscal year. 

3 ‘‘(D) POSITIONS NOT DISTRIBUTED DUR4 ING FISCAL YEAR 2014.—If the number of resi5 dent full-time equivalent positions distributed 

6 under this paragraph in fiscal year 2014 is less 

7 than the aggregate number of positions avail8 able for distribution in the fiscal year under 

9 subparagraph (B), the Secretary shall conduct 

10 an application and distribution process in sub11 sequent fiscal years until such time as the ag12 gregate number of positions distributed under 

13 this paragraph is equal to the aggregate num14 ber under subparagraph (B). 

15 ‘‘(E) CONSIDERATION IN DISTRIBUTION.— 

16 In determining for which hospitals the increase 

17 in the otherwise applicable resident limit is pro18 vided under this paragraph, the Secretary shall 

19 prioritize training programs with an emphasis 

20 on community-based training, and shall 

21 prioritize hospitals with a demonstrated likeli22 hood of filling the positions with residents who 

23 will practice in health professional shortage 

24 areas (as defined by the National Health Serv25 ice Corps under section 332 of the Public 


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1 Health Service Act (42 U.S.C. 254e)) or with 

2 medically underserved populations (as defined 

3 in section 330(b)(3) of the Public Health Serv4 ice Act (42 U.S.C. 254b(b)(3))), as determined 

5 by the Secretary. 

6 ‘‘(F) DEFINITION OF OTHERWISE APPLICA7 BLE RESIDENT LIMIT.—In this paragraph, the 

8 term ‘otherwise applicable resident limit’ 

9 means, with respect to a hospital, the limit oth10 erwise applicable under subparagraphs (F)(i) 

11 and (H) of paragraph (4) on the resident level 

12 (as defined in paragraph (7)(C)(i)) for the hos13 pital determined without regard to this para14 graph but taking into account paragraphs 

15 (7)(A), (7)(B), (8)(A), and (8)(B).’’. 

16 (2) IME.— 

17 (A) IN GENERAL.—Section 

18 1886(d)(5)(B)(v) of the Social Security Act (42 

19 U.S.C. 1395ww(d)(5)(B)(v)), in the second sen20 tence, is amended by striking ‘‘subsections 

21 (h)(7) and (h)(8)’’ and inserting ‘‘subsections 

22 (h)(7), (h)(8), and (h)(9)’’. 

23 (B) CONFORMING PROVISION.—Section 

24 1886(d)(5)(B) of the Social Security Act (42 

25 U.S.C. 1395ww(d)(5)(B)) is amended— 


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1 (i) by redesignating clause (x), as 

2 added by section 5505(b) of the Patient 

3 Protection and Affordable Care Act (Public 

4 Law 111–148), as clause (xi) and moving 

5 such clause 4 ems to the left; and 

6 (ii) by adding after clause (xi), as re7 designated by subparagraph (A), the fol8 lowing clause: 

9 ‘‘(xii) For discharges occurring on or after July 

10 1, 2014, insofar as an additional payment amount 

11 under this subparagraph is attributable to resident 

12 positions distributed to a hospital under subsection 

13 (h)(9), the indirect teaching adjustment factor shall 

14 be computed in the same manner as provided under 

15 clause (ii) with respect to such resident positions.’’. 

16 (b) REQUIREMENTS TO IMPROVE TRANSPARENCY.— 

17 (1) IN GENERAL.—Section 1886(h) of the So18 cial Security Act (42 U.S.C. 1395ww(h)), as amend19 ed by subsection (a)(1), is amended by adding at the 

20 end the following new paragraph: 

21 ‘‘(10) REQUIREMENTS.— 

22 ‘‘(A) IN GENERAL.—Notwithstanding the 

23 preceding provisions of this subsection, for fis24 cal year 2014 and subsequent fiscal years, a 

25 hospital shall not receive any payments under 


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1 this subsection or subsection (d)(5)(B) (or any 

2 other payments under this title for graduate 

3 medical education costs) in a fiscal year unless 

4 the hospital complies with the following require5 ments, as determined by the Secretary: 

6 ‘‘(i) The hospital has an approved 

7 medical residency program in— 

8 ‘‘(I) family medicine; or 

9 ‘‘(II) adult or all-age primary 

10 care. 

11 ‘‘(ii) Each fiscal year (beginning with 

12 fiscal year 2014), the hospital submits to 

13 the Secretary a report that contains the 

14 following information with respect to resi15 dents of the hospital: 

16 ‘‘(I) The total amount of money 

17 generated by the residents (by resi18 dency type) in each year of their resi19 dency program. 

20 ‘‘(II) The total amount of Fed21 eral funding provided to the hospital 

22 for training residents, by residency 

23 type, in each year of the residency 

24 program. 


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1 ‘‘(III) The average number of in2 patient and outpatient encounters per 

3 year by residency type in inpatient 

4 and outpatient settings. 

5 ‘‘(IV) A justification for the hos6 pital’s allocation of residency slots 

7 across specialties and subspecialties 

8 that is responsive to local and na9 tional health care workforce needs and 

10 recommendations put forth by the Na11 tional Health Care Workforce Com12 mission. 

13 ‘‘(V) A detailed breakdown of 

14 how the hospital uses amounts re15 ceived under this subsection and 

16 under subsection (d)(5)(B). 

17 ‘‘(B) PUBLIC AVAILABILITY.—Not later 

18 than 30 days after receiving the report under 

19 subparagraph (A)(ii), the Secretary shall post 

20 the information described in subclauses (I) 

21 through (VI) of such subparagraph on the 

22 Internet Website of the Centers for Medicare & 

23 Medicaid Services.’’. 

24 (2) IME.—Section 1886(d)(5)(B) of the Social 

25 Security Act (42 U.S.C. 1395ww(d)(5)(B)), as 


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1 amended by subsection (a)(2)(B), is amended by 

2 adding at the end the following new clause: 

3 ‘‘(xiii) The requirements under subsection 

4 (h)(10) shall apply to payments under this subpara5 graph in the same manner as such requirements 

6 apply to payments under such subsection.’’. 

7 SEC. 8. HEALTH CARE FOR THE UNINSURED. 

8 A hospital or health care provider that accepts any 

9 payment under the Medicare program under title XVIII 

10 of the Social Security Act (42 U.S.C. 1395 et seq.) or the 

11 Medicaid program under title XIX of the Social Security 

12 Act (42 U.S.C. 1396 et seq.) shall not charge an individual 

13 without health insurance coverage an amount for any med14 ical service that exceeds the amount such hospital or 

15 health care provider receives under the Medicare program 

16 for such service. 

Æ 


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