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[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 676 Introduced in House (IH)]

108th CONGRESS
  1st Session
                                H. R. 676

 To provide for comprehensive health insurance coverage for all United 
               States residents, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           February 11, 2003

      Mr. Conyers (for himself, Mr. McDermott, Mr. Kucinich, Mrs. 
 Christensen, Mr. Scott of Virginia, Ms. Lee, Ms. Norton, Mr. Davis of 
 Illinois, Mr. Owens, Mr. Jackson of Illinois, Mr. Hinchey, Mr. Payne, 
Mr. Cummings, Ms. Kilpatrick, Mr. Hastings of Florida, Mr. Fattah, Mr. 
Grijalva, Mr. Towns, Mr. Lewis of Georgia, Mr. Gutierrez, Mr. Thompson 
  of Mississippi, Ms. Carson of Indiana, Mr. Pastor, Ms. Woolsey, Mr. 
Clay, and Mr. Rangel) introduced the following bill; which was referred 
    to the Committee on Energy and Commerce, and in addition to the 
 Committees on Ways and Means, Resources, and Veterans' Affairs, 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 provide for comprehensive health insurance coverage for all United 
               States residents, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``United States 
National Health Insurance Act (or the Expanded and Improved Medicare 
for All Act)''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Definitions and terms.
                   TITLE I--ELIGIBILITY AND BENEFITS

Sec. 101. Eligibility and registration.
Sec. 102. Benefits and portability.
Sec. 103. Qualification of participating providers.
Sec. 104. Prohibition against duplicating coverage.
                           TITLE II--FINANCES

                   Subtitle A--Budgeting and Payments

Sec. 201. Budgeting process.
Sec. 202. Payment of providers and health care clinicians.
Sec. 203. Payment for long-term care.
Sec. 204. Mental health services.
Sec. 205. Payment for prescription medications, medical supplies, and 
                            medically necessary assistive equipment.
Sec. 206. Consultation in establishing reimbursement levels.
                          Subtitle B--Funding

Sec. 211. Overview: funding the USNHI Program.
Sec. 212. Appropriations for existing programs for uninsured and 
                            indigent.
                       TITLE III--ADMINISTRATION

Sec. 301. Public administration; appointment of Director.
Sec. 302. Quality and cost control.
Sec. 303. Regional and State administration; employment of displaced 
                            clerical workers.
Sec. 304. Confidential Electronic Patient Record System.
Sec. 305. National Board of Universal Quality and Access.
                    TITLE IV--ADDITIONAL PROVISIONS

Sec. 401. Treatment of VA and IHS health programs.
Sec. 402. Public health and prevention.
Sec. 403. Reduction in health disparities.
                        TITLE V--EFFECTIVE DATE

Sec. 501. Effective date.

SEC. 2. DEFINITIONS AND TERMS.

    In this Act:
            (1) USNHI program; program.--The terms ``USNHI Program'' 
        and ``Program'' mean the program of benefits provided under 
        this Act and, unless the context otherwise requires, the 
        Secretary with respect to functions relating to carrying out 
        such program.
            (2) National board of universal quality and access.--The 
        term ``National Board of Universal Quality and Access'' means 
        such Board established under section 305.
            (3) Regional office.--The term ``regional office'' means a 
        regional office established under section 303.
            (4) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (5) Director.--The term ``Director'' means, in relation to 
        the Program, the Director appointed under section 301.

                   TITLE I--ELIGIBILITY AND BENEFITS

SEC. 101. ELIGIBILITY AND REGISTRATION.

    (a) In General.--All individuals residing in the United States 
(including any territory of the United States) are covered under the 
USNHI Program entitling them to a universal, best quality standard of 
care. Each such individual shall receive a card with a unique number in 
the mail. An individual's social security number shall not be used for 
purposes of registration under this section.
    (b) Registration.--Individuals and families shall receive a United 
States National Health Insurance Card in the mail, after filling out a 
United States National Health Insurance application form at a health 
care provider. Such application form shall be no more than 2 pages 
long.
    (c) Presumption.--Individuals who present themselves for covered 
services from a participating provider shall be presumed to be eligible 
for benefits under this Act, but shall complete an application for 
benefits in order to receive a United States National Health Insurance 
Card and have payment made for such benefits.

SEC. 102. BENEFITS AND PORTABILITY.

    (a) In General.--The health insurance benefits under this Act cover 
all medically necessary services, including--
            (1) primary care and prevention;
            (2) inpatient care;
            (3) outpatient care;
            (4) emergency care;
            (5) prescription drugs;
            (6) durable medical equipment;
            (7) long term care;
            (8) mental health services;
            (9) the full scope of dental services (other than cosmetic 
        dentistry);
            (10) substance abuse treatment services;
            (11) chiropractic services; and
            (12) basic vision care and vision correction (other than 
        laser vision correction for cosmetic purposes).
    (b) Portability.--Such benefits are available through any licensed 
health care clinician anywhere in the United States that is legally 
qualified to provide the benefits.
    (c) No Cost-Sharing.--No deductibles, copayments, coinsurance, or 
other cost-sharing shall be imposed with respect to covered benefits.

SEC. 103. QUALIFICATION OF PARTICIPATING PROVIDERS.

    (a) Requirement To Be Public or Non-Profit.--
            (1) In general.--No institution may be a participating 
        provider unless it is a public or not-for-profit institution.
            (2) Conversion of investor-owned providers.--Investor-owned 
        providers of care opting to participate shall be required to 
        convert to not-for-profit status.
            (3) Compensation for conversion.--The owners of such 
        investor-owned providers shall be compensated for the actual 
        appraised value of converted facilities used in the delivery of 
        care.
            (4) Funding.--There are authorized to be appropriated from 
        the Treasury such sums as are necessary to compensate investor-
        owned providers as provided for under paragraph (3).
            (5) Requirements.--The conversion to a not-for-profit 
        health care system shall take place over a 15-year period, 
        through the sale of US Treasury Bonds. Payment for conversions 
        under paragraph (3) shall not be made for loss of business 
        profits, but may be made only for costs associated with the 
        conversion of real property and equipment.
    (b) Quality Standards.--
            (1) In general.--Health care delivery facilities must meet 
        regional and State quality and licensing guidelines as a 
        condition of participation under such program, including 
        guidelines regarding safe staffing and quality of care.
            (2) Licensure requirements.--Participating clinicians must 
        be licensed in their State of practice and meet the quality 
        standards for their area of care. No clinician whose license is 
        under suspension or who is under disciplinary action in any 
        State may be a participating provider.
    (c) Participation of Health Maintenance Organizations.--
            (1) In general.--Non-profit health maintenance 
        organizations that actually deliver care in their own 
        facilities and employ clinicians on a salaried basis may 
        participate in the program and receive global budgets or 
        capitation payments as specified in section 202.
            (2) Exclusion of certain health maintenance 
        organizations.--Other health maintenance organizations, 
        including those which principally contract to pay for services 
        delivered by non-employees, shall be classified as insurance 
        plans. Such organizations shall not be participating providers, 
        and are subject to the regulations promulgated by reason of 
        section 104(a) (relating to prohibition against duplicating 
        coverage).
    (d) Freedom of Choice.--Patients shall have free choice of 
participating physicians and other clinicians, hospitals, and inpatient 
care facilities.

SEC. 104. PROHIBITION AGAINST DUPLICATING COVERAGE.

    (a) In General.--It is unlawful for a private health insurer to 
sell health insurance coverage that duplicates the benefits provided 
under this Act.
    (b) Construction.--Nothing in this Act shall be construed as 
prohibiting the sale of health insurance coverage for any additional 
benefits not covered by this Act, such as for cosmetic surgery or other 
services and items that are not medically necessary.

                           TITLE II--FINANCES

                   Subtitle A--Budgeting and Payments

SEC. 201. BUDGETING PROCESS.

    (a) Establishment of Operating Budget and Capital Expenditures 
Budget.--
            (1) In general.--To carry out this Act there are 
        established on an annual basis consistent with this title--
                    (A) an operating budget;
                    (B) a capital expenditures budget;
                    (C) reimbursement levels for providers consistent 
                with subtitle B; and
                    (D) a health professional education budget, 
                including amounts for the continued funding of resident 
                physician training programs.
            (2) Regional allocation.--After Congress appropriates 
        amounts for the annual budget for the USNHI Program, the 
        Director shall provide the regional offices with an annual 
        funding allotment to cover the costs of each region's 
        expenditures. Such allotment shall cover global budgets, 
        reimbursements to clinicians, and capital expenditures. 
        Regional offices may receive additional funds from the national 
        program at the discretion of the Director.
    (b) Operating Budget.--The operating budget shall be used for--
            (1) payment for services rendered by physicians and other 
        clinicians;
            (2) global budgets for institutional providers;
            (3) capitation payments for capitated groups; and
            (4) administration of the Program.
    (c) Capital Expenditures Budget.--The capital expenditures budget 
shall be used for funds needed for--
            (1) the construction or renovation of health facilities; 
        and
            (2) for major equipment purchases.
    (d) Prohibition Against Co-Mingling Operations and Capital 
Improvement Funds.--It is prohibited to use funds under this Act that 
are earmarked--
            (1) for operations for capital expenditures; or
            (2) for capital expenditures for operations.

SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.

    (a) Establishing Global Budgets; Monthly Lump Sum.--
            (1) In general.--The USNHI Program, through its regional 
        offices, shall pay each hospital, nursing home, community or 
        migrant health center, home care agencies, or other 
        institutional provider or pre-paid group practice a monthly 
        lump sum to cover all operating expenses under a global budget.
            (2) Establishment of global budgets.--The global budget of 
        a provider shall be set through negotiations between providers 
        and regional directors, but are subject to the approval of the 
        Director. The budget shall be negotiated annually, based on 
        past expenditures, projected changes in levels of services, 
        wages and input, costs, and proposed new and innovative 
        programs.
    (b) Three Payment Options for Physicians and Certain Other Health 
Professionals.--
            (1) In general.--The Program shall pay physicians, 
        dentists, doctors of osteopathy, psychologists, chiropractors, 
        doctors of optometry, nurse practitioners, nurse midwives, 
physicians' assistants, and other advanced practice clinicians as 
licensed and regulated by the States by the following payment methods:
                    (A) Fee for service payment under paragraph (2).
                    (B) Salaried positions in institutions receiving 
                global budgets under paragraph (3).
                    (C) Salaried positions within group practices or 
                non-profit health maintenance organizations receiving 
                capitation payments under paragraph (4).
            (2) Fee for service.--
                    (A) In general.--The Program shall negotiate a 
                simplified fee schedule with clinician representatives, 
                after close consultation with the National Board of 
                Universal Quality and Access and regional and State 
                directors.
                    (B) Considerations.--In establishing such schedule, 
                the Director shall take into consideration regional 
                differences in reimbursement, but strive for a uniform 
                national standard.
                    (C) Final guidelines.--The regional directors shall 
                be responsible for promulgating final guidelines to all 
                providers.
                    (D) Billing.--Under the Act physicians shall submit 
                bills to the regional director on a simple form, or via 
                computer. Interest shall be paid to providers whose 
                bills are not paid within 30 days of submission.
                    (E) No balance billing.--Licensed health care 
                clinicians who accept any payment from the USNHI 
                Program may not bill any patient for any covered 
                service.
                    (F) Uniform computer electronic billing system.--
                The Director shall make a good faith effort to create a 
                uniform computerized electronic billing system, 
                including in those areas of the United States where 
                electronic billing is not yet established.
            (3) Salaries within institutions receiving global 
        budgets.--
                    (A) In general.--In the case of an institution, 
                such as a hospital, health center, group practice, 
                community and migrant health center, or a home care 
                agency that elects to be paid a monthly global budget 
                for the delivery of health care as well as for 
                education and prevention programs, physicians employed 
                by such institutions shall be reimbursed through a 
                salary included as part of such a budget.
                    (B) Salary ranges.--Salary ranges for health care 
                providers shall be determined in the same way as fee 
                schedules under paragraph (2).
            (4) Salaries within capitated groups.--
                    (A) In general.--Health maintenance organizations, 
                group practices, and other institutions may elect to be 
                paid capitation premiums to cover all outpatient, 
                physician, and medical home care provided to 
                individuals enrolled to receive benefits through the 
                organization or entity.
                    (B) Scope.--Such capitation may include the costs 
                of services of licensed physicians and other licensed, 
                independent practitioners provided to inpatients. Other 
                costs of inpatient and institutional care shall be 
                excluded from capitation payments, and shall be covered 
                under institutions' global budgets.
                    (C) Prohibition of selective enrollment.--Selective 
                enrollment policies are prohibited, and patients shall 
                be permitted to enroll or disenroll from such 
                organizations or entities with appropriate notice.
                    (D) Health maintenance organizations.--Under this 
                Act--
                            (i) health maintenance organizations shall 
                        be required to reimburse physicians based on a 
                        salary; and
                            (ii) financial incentives between such 
                        organizations and physicians based on 
                        utilization are prohibited.

SEC. 203. PAYMENT FOR LONG-TERM CARE.

    (a) Allotment for Regions.--The Program shall provide for each 
region a single budgetary allotment to cover a full array of long-term 
care services under this Act.
    (b) Regional Budgets.--Each region shall provide a global budget to 
local long-term care providers for the full range of needed services, 
including in-home, nursing home, and community based care.
    (c) Basis for Budgets.--Budgets for long-term care services under 
this section shall be based on past expenditures, financial and 
clinical performance, utilization, and projected changes in service, 
wages, and other related factors.
    (d) Favoring Non-Institutional Care.--All efforts shall be made 
under this Act to provide long-term care in a home- or community-based 
setting, as opposed to institutional care.

SEC. 204. MENTAL HEALTH SERVICES.

    (a) In General.--The Program shall provide coverage for all 
medically necessary mental health care on the same basis as the 
coverage for other conditions. Licensed mental health clinicians shall 
be paid in the same manner as specified for other health professionals, 
as provided for in section 202(b).
    (b) Favoring Community-Based Care.--The USNHI Program shall cover 
supportive residences, occupational therapy, and ongoing mental health 
and counseling services outside the hospital for patients with serious 
mental illness. In all cases the highest quality and most effective 
care shall be delivered, and, for some individuals, this may mean 
institutional care.

SEC. 205. PAYMENT FOR PRESCRIPTION MEDICATIONS, MEDICAL SUPPLIES, AND 
              MEDICALLY NECESSARY ASSISTIVE EQUIPMENT.

    (a) Negotiated Prices.--The prices to be paid each year under this 
Act for covered pharmaceuticals, medical supplies, and medically 
necessary assistive equipment shall be negotiated annually by the 
Program.
    (b) Prescription Drug Formulary.--
            (1) In general.--The Program shall establish a prescription 
        drug formulary system, which shall encourage best-practices in 
        prescribing and discourage the use of ineffective, dangerous, 
        or excessively costly medications when better alternatives are 
        available.
            (2) Promotion of use of generics.--The formulary shall 
        promote the use of generic medications but allow the use of 
        brand-name and off-formulary medications when indicated for a 
        specific patient or condition.
            (3) Formulary updates and petition rights.--The formulary 
        shall be updated frequently and clinicians and patients may 
        petition their region or the Director to add new 
        pharmaceuticals or to remove ineffective or dangerous 
        medications from the formulary.

SEC. 206. CONSULTATION IN ESTABLISHING REIMBURSEMENT LEVELS.

    Reimbursement levels under this subtitle shall be set after close 
consultation with regional and State Directors and after the annual 
meeting of National Board of Universal Quality and Access.

                          Subtitle B--Funding

SEC. 211. OVERVIEW: FUNDING THE USNHI PROGRAM.

    (a) In General.--The USNHI Program is to be funded as provided in 
subsections (b) and (c).
    (b) Annual Appropriation for Funding of USNHI Program.--There are 
authorized to be appropriated to carry out this Act such sums as may be 
necessary.
    (c) Intent.--Sums appropriated pursuant to subsection (b) shall be 
paid for--
            (1) by vastly reducing paperwork;
            (2) by requiring a rational bulk procurement of 
        medications;
            (3) from existing sources of Federal government revenues 
        for health care;
            (4) by increasing personal income taxes on the top 5 
        percent income earners;
            (5) by instituting a modest payroll tax; and
            (6) by instituting a small tax on stock and bond 
        transactions.

SEC. 212. APPROPRIATIONS FOR EXISTING PROGRAMS FOR UNINSURED AND 
              INDIGENT.

    Notwithstanding any other provision of law, there are hereby 
transferred and appropriated to carry out this Act, amounts equivalent 
to the amounts the Secretary estimates would have been appropriated and 
expended for Federal public health care programs for the uninsured and 
indigent, including funds appropriated under the Medicare program under 
title XVIII of the Social Security Act, under the Medicaid program 
under title XIX of such Act, and under the Children's Health Insurance 
Program under title XXI of such Act.

                       TITLE III--ADMINISTRATION

SEC. 301. PUBLIC ADMINISTRATION; APPOINTMENT OF DIRECTOR.

    (a) In General.--Except as otherwise specifically provided, this 
Act shall be administered by the Secretary through a Director appointed 
by the Secretary.
    (b) Long-Term Care.--The Director shall appoint a director for 
long-term care who shall be responsible for administration of this Act 
and ensuring the availability and accessibility of high quality long-
term care services.
    (c) Mental Health.--The Director shall appoint a director for 
mental health who shall be responsible for administration of this Act 
and ensuring the availability and accessibility of high quality mental 
health services.

SEC. 302. OFFICE OF QUALITY CONTROL.

    The Director shall appoint a director for an Office of Quality 
Control. Such director shall, after consultation with state and 
regional directors, provide annual recommendations to Congress, the 
President, the Secretary, and other Program officials on how to ensure 
the highest quality health care service delivery. The director of the 
Office of Quality Control shall conduct an annual review on the 
adequacy of medically necessary services, and shall make 
recommendations of any proposed changes to the Congress, the President, 
the Secretary, and other USNHI program officials.

SEC. 303. REGIONAL AND STATE ADMINISTRATION; EMPLOYMENT OF DISPLACED 
              CLERICAL WORKERS.

    (a) Use of Regional Offices.--The Program shall establish and 
maintain regional offices. Such regional offices shall replace all 
regional Medicare offices.
    (b) Appointment of Regional and State Directors.--In each such 
regional office there shall be--
            (1) one regional director appointed by the Director; and
            (2) for each State in the region, a deputy director (in 
        this Act referred to as a ``State Director'') appointed by the 
        governor of that State.
    (c) Regional Office Duties.--
            (1) In general.--Regional offices of the Program shall be 
        responsible for--
                    (A) coordinating funding to health care providers 
                and physicians; and
                    (B) coordinating billing and reimbursements with 
                physicians and health care providers through a State-
                based reimbursement system.
    (d) State Director's Duties.--Each State Director shall be 
responsible for the following duties:
            (1) Providing an annual state health care needs assessment 
        report to the National Board of Universal Quality and Access, 
        and the regional board, after a thorough examination of health 
        needs, in consultation with public health officials, 
        clinicians, patients and patient advocates.
            (2) Health planning, including oversight of the placement 
        of new hospitals, clinics, and other health care delivery 
        facilities.
            (3) Health planning, including oversight of the purchase 
        and placement of new health equipment to ensure timely access 
        to care and to avoid duplication.
            (4) Submitting global budgets to the regional director.
            (5) Recommending changes in provider reimbursement or 
        payment for delivery of health services in the State.
            (6) Establishing a quality assurance mechanism in the State 
        in order to minimize both under utilization and over 
        utilization and to assure that all providers meet high quality 
        standards.
            (7) Reviewing program disbursements on a quarterly basis 
        and recommending needed adjustments in fee schedules needed to 
        achieve budgetary targets and assure adequate access to needed 
        care.
    (e) First Priority in Retraining and Job Placement.--The Program 
shall provide that clerical and administrative workers in insurance 
companies, doctors offices, hospitals, nursing facilities and other 
facilities whose jobs are eliminated due to reduced administration, 
should have first priority in retraining and job placement in the new 
system.

SEC. 304. CONFIDENTIAL ELECTRONIC PATIENT RECORD SYSTEM.

    (a) In General.--The Secretary shall create a standardized, 
confidential electronic patient record system in accordance with laws 
and regulations to maintain accurate patient records and to simplify 
the billing process, thereby reducing medical errors and bureaucracy.
    (b) Patient Option.--Notwithstanding that all billing shall be 
preformed electronically, patients shall have the option of keeping any 
portion of their medical records separate from their electronic medical 
record.

SEC. 305. NATIONAL BOARD OF UNIVERSAL QUALITY AND ACCESS.

    (a) Establishment.--
            (1) In general.--There is established a National Board of 
        Universal Quality and Access (in this section referred to as 
        the ``Board'') consisting of 15 members appointed by the 
        President, by and with the advice and consent of the Senate.
            (2) Qualifications.--The appointed members of the Board 
        shall include at least one of each of the following:
                    (A) Health care professionals.
                    (B) Representatives of institutional providers of 
                health care.
                    (C) Representatives of health care advocacy groups.
                    (D) Representatives of labor unions.
                    (E) Citizen patient advocates.
            (3) Terms.--Each member shall be appointed for a term of 6 
        years, except that the President shall stagger the terms of 
        members initially appointed so that the term of no more than 3 
        members expires in any year.
            (4) Prohibition on conflicts of interest.--No member of the 
        Board shall have a financial conflict of interest with the 
        duties before the Board.
    (b) Duties.--
            (1) In general.--The Board shall meet at least twice per 
        year and shall advise the Secretary and the Director on a 
        regular basis to ensure quality, access, and affordability.
            (2) Specific issues.--The Board shall specifically address 
        the following issues:
                    (A) Access to care.
                    (B) Quality improvement.
                    (C) Efficiency of administration.
                    (D) Adequacy of budget and funding.
                    (E) Appropriateness of reimbursement levels of 
                physicians and other providers.
                    (F) Capital expenditure needs.
                    (G) Long-term care.
                    (H) Mental health and substance abuse services.
                    (I) Staffing levels and working conditions in 
                health care delivery facilities.
            (3) Establishment of universal, best quality standard of 
        care.--The Board shall specifically establish a universal, best 
        quality of standard of care with respect to--
                    (A) appropriate staffing levels;
                    (B) appropriate medical technology;
                    (C) design and scope of work in the health 
                workplace; and
                    (D) best practices.
            (4) Twice-a-year report.--The Board shall report its 
        recommendations twice each year to the Secretary, the Director, 
        Congress, and the President.
    (c) Compensation, Etc.--The following provisions of section 1805 of 
the Social Security Act shall apply to the Board in the same manner as 
they apply to the Medicare Payment Assessment Commission (except that 
any reference to the Commission or the Comptroller General shall be 
treated as references to the Board and the Secretary, respectively):
            (1) Subsection (c)(4) (relating to compensation of Board 
        members).
            (2) Subsection (c)(5) (relating to chairman and vice 
        chairman)
            (3) Subsection (c)(6) (relating to meetings).
            (4) Subsection (d) (relating to director and staff; experts 
        and consultants).
            (5) Subsection (e) (relating to powers).

                    TITLE IV--ADDITIONAL PROVISIONS

SEC. 401. TREATMENT OF VA AND IHS HEALTH PROGRAMS.

    This Act provides for health programs of the Department of 
Veterans' Affairs and of the Indian Health Service to initially remain 
independent for the 5-year period that begins on the date of the 
establishment of the USNHI program, but after such period those 
programs shall be integrated into the USNHI program.

SEC. 402. PUBLIC HEALTH AND PREVENTION.

    It is the intent of this Act that the Program at all times stress 
the importance of good public health through the prevention of 
diseases.

SEC. 403. REDUCTION IN HEALTH DISPARITIES.

    It is the intent of this Act to reduce health disparities by race, 
ethnicity, income and geographic region, and to provide high quality, 
cost-effective, culturally appropriate care to all individuals 
regardless of race, ethnicity, sexual orientation, or language.

                        TITLE V--EFFECTIVE DATE

SEC. 501. EFFECTIVE DATE.

    Except as otherwise specifically provided, this Act shall take 
effect on January 1, 2005, and shall apply to items and services 
furnished on or after such date.
                                 <all>
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