I

103D CONGRESS

1ST SESSION H. R. 1691

To provide universal access for all Americans to basic health care services

and long-term care services.

IN THE HOUSE OF REPRESENTATIVES

APRIL 5, 1993

Mr. ANDREWS of Maine introduced the following bill; which was referred jointly to the Committees on Energy and Commerce, Ways and Means, Education and Labor, Rules, Armed Services, Veterans’ Affairs, and Post Office and Civil Service

A BILL

To provide universal access for all Americans to basic health

care services and long-term care services.

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; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘National Health Security Act of 1993’’.

6 (b) TABLE OF CONTENTS.—The table of contents for

7 this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Statement of principles.

Sec. 3. General definitions.

TITLE I—ELIGIBILITY AND ENROLLMENT
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Sec. 101. Eligibility and entitlement.

Sec. 102. Enrollment.

Sec. 103. Portability.

TITLE II—BENEFITS

Subtitle A—Health Care Services

Sec. 201. Covered health care services.

Sec. 202. Limitations and exclusions.

Sec. 203. Patient cost-sharing.

Subtitle B—Long-Term Care Services

Sec. 211. Covered long-term care services.

Sec. 212. Long-Term Care Services Assessment Commission.

Subtitle C—Modification of Services

Sec. 221. Modification of services covered under this Act.

TITLE III—FEDERAL AND STATE ADMINISTRATION

Subtitle A—Federal Administration

Sec. 301. Federal Health Board.

Sec. 302. Federal Health Advisory Council.

Sec. 303. Federal Health Priorities Council.

Sec. 304. Authorization of appropriations.

Subtitle B—State Administration

Sec. 311. State programs.

Sec. 312. Use of fiscal intermediaries.

Sec. 313. State waivers; managed care.

Sec. 314. State regional consortia.

Sec. 315. Grants to States.

Sec. 316. Technical assistance to States.

TITLE IV—FINANCING

Subtitle A—Health Budgets

Sec. 401. National health budget.

Sec. 402. Payments to States.

Sec. 403. State program budgets.

Subtitle B—Payments to Providers

Sec. 411. Payments to hospitals and other health care and long-term care institutions.

Sec. 412. Payments for practitioners services.

Sec. 413. Special nonphysician practitioner provisions.

Sec. 414. Mandatory assignment.

Subtitle C—Revenues

Sec. 421. Federal sources of revenues.
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Sec. 422. Tax treatment of American Health Security Plan and private health

and long-term care insurance.

Sec. 423. Federal Health Trust Fund.

Sec. 424. State sources of revenues.

TITLE V—CONGRESSIONAL CONSIDERATION

Sec. 501. Rules governing congressional consideration.

TITLE VI—PRIVATE OPTIONS

Sec. 601. Private supplemental insurance.

Sec. 602. Option to purchase duplicative private insurance.

Sec. 603. Limits on private insurance.

TITLE VII—EXPANSION OF OUTCOMES RESEARCH AND

DELIVERY OF SERVICES IN UNDERSERVED AREAS

Sec. 701. Expansion of outcomes research.

Sec. 702. National health service corps.

Sec. 703. Community and migrant health centers.

TITLE VIII—MALPRACTICE REFORM

Sec. 801. Grants to States.

Sec. 802. Criteria for State malpractice reforms.

Sec. 803. Authorization of appropriations.

TITLE IX—EFFECTIVE DATES; TERMINATIONS; TRANSITION;

RELATION TO ERISA.

Sec. 901. Effective dates.

Sec. 902. Termination of other programs.

Sec. 903. Transition.

Sec. 904. Relation to ERISA.

1 SEC. 2. STATEMENT OF PRINCIPLES.

2 The principles of this Act are—

3 (1) to provide universal access to basic health

4 care services for all Americans regardless of their fi5 nancial and medical conditions;

6 (2) to establish the institutional and political

7 capacity to control the Nation’s escalating health

8 care costs and eliminate administrative waste;

9 (3) to ensure the portability of health care cov10 erage to all regions of the country;
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1 (4) to build on the strengths of American fed2 eralism, with the Federal Government contributing

3 progressive financing and specifying minimum na4 tional standards while State governments supply ad5 ditional funding and administer the program with

6 the flexibility needed to address the specific concerns

7 of each region;

8 (5) to maintain the proven advantages of the

9 American health care delivery system, including pri10 vate practice, the freedom to choose among practi11 tioners, and superiority in biomedical technology;

12 (6) to encourage the effective use of preventive

13 and primary care;

14 (7) to enhance the autonomy of practitioners by

15 limiting the intrusiveness of government intervention

16 in the actual delivery of care;

17 (8) to promote the role of competition among

18 practitioners and to encourage innovation that re19 sults in higher quality and more efficient care;

20 (9) to reduce the incentives providers face to

21 perform medically unnecessary or inappropriate serv22 ices;

23 (10) to reinforce the public accountability of the

24 health care system, permitting explicit and open de-
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1 liberation about the allocation of society’s resources

2 to health care; and

3 (11) to provide that all Americans share in the

4 responsibility of maintaining an efficient health care

5 system.

6 SEC. 3. GENERAL DEFINITIONS.

7 (a) IN GENERAL.—For purposes of this Act:

8 (1) The term ‘‘Board’’ means the Federal

9 Health Board established in section 301.

10 (2) The term ‘‘Advisory Council’’ means the

11 Federal Health Care Advisory Council established in

12 section 302.

13 (3) The term ‘‘Priorities Council’’ means the

14 Federal Health Priorities Council established in sec15 tion 303.

16 (4) The term ‘‘State program’’ means a State

17 health care program approved under section 311.

18 (5) The term ‘‘State’’ includes the District of

19 Columbia, the Commonwealth of Puerto Rico, the

20 United States Virgin Islands, Guam, American

21 Samoa, and the Commonwealth of the Northern

22 Mariana Islands.

23 (6) The term ‘‘Trust Fund’’ means the Federal

24 Health Trust Fund established in section 423.
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1 (b) OTHER DEFINITIONS.—Except as otherwise pro2 vided, the definitions contained in section 1861 of the So3 cial Security Act (42 U.S.C. 1395x), as in effect on the

4 day before the date of the enactment of this Act, shall

5 apply in this Act.

6 TITLE I—ELIGIBILITY AND

7 ENROLLMENT

8 SEC. 101. ELIGIBILITY AND ENTITLEMENT.

9 (a) IN GENERAL.—Every individual who is a resident

10 of the United States and is a citizen or national of the

11 United States or lawful resident alien (as defined in sub12 section (d)) is entitled to health care services and long13 term care services covered under this Act in the State in

14 which the individual maintains a primary residence.

15 (b) TREATMENT OF CERTAIN NONIMMIGRANTS.—

16 (1) IN GENERAL.—The Board may make eligi17 ble for health care services and long-term care serv18 ices covered under this Act such classes of aliens ad19 mitted to the United States as nonimmigrants as the

20 Board may provide.

21 (2) CONSIDERATION.—In providing for eligi22 bility under paragraph (1), the Board shall consider

23 reciprocity in health care and long-term care services

24 offered to United States citizens who are

25 nonimmigrants in other foreign states, and such
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1 other factors as the Board determines to be appro2 priate.

3 (c) TREATMENT OF OTHER INDIVIDUALS.—The

4 Board may make eligible for health care services and long5 term care services covered under this Act other individuals

6 not described in subsection (a) or (b), and regulate the

7 nature of the eligibility of such individuals for the pur8 poses of fulfilling the following criteria:

9 (1) Preserving the public health of commu10 nities.

11 (2) Compensating States for the additional

12 health care financing burdens created by such indi13 viduals.

14 (3) Preventing adverse financial and medical

15 consequences of uncompensated care.

16 (4) Inhibiting travel and immigration to the

17 United States for the sole purpose of obtaining

18 health care services or long-term care services cov19 ered under this Act.

20 (d) LAWFUL RESIDENT ALIEN DEFINED.—For pur21 poses of this section, the term ‘‘lawful resident alien’’

22 means an alien lawfully admitted for permanent residence

23 and any other alien lawfully residing permanently in the

24 United States under color of law, including an alien with

25 lawful temporary resident status under section 210, 210A,
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1 or 245A of the Immigration and Nationality Act (8 U.S.C.

2 1160, 1161, or 1255a).

3 SEC. 102. ENROLLMENT.

4 (a) IN GENERAL.—Each State program shall provide

5 a mechanism for enrollment of individuals entitled to bene6 fits under this Act and, in conjunction with such enroll7 ment, the issuance of a State health insurance card which

8 may be used for purposes of identification and processing

9 of claims for benefits under this Act.

10 (b) ENROLLMENT AT BIRTH OR IMMIGRATION.—The

11 mechanism under subsection (a) shall include a process

12 for the automatic enrollment of individuals at the time of

13 birth in the State or at the establishment of permanent

14 residence in the State, including at the time of immigra15 tion into the United States, other acquisition of lawful

16 resident status in the United States, or eligibility for other

17 individuals established under section 101(c).

18 SEC. 103. PORTABILITY.

19 To ensure continuous access to health care services

20 and long-term care services covered under this Act, each

21 State program—

22 (1) shall utilize a uniform claims form as devel23 oped by the Board;

24 (2) shall not impose any minimum period of

25 residence in the State, or waiting period, in excess
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1 of 3 months before residents of the State are enti2 tled to such services;

3 (3) shall provide continuation of payment for

4 such services to individuals who have terminated

5 their residence in the State and established their

6 residence in another State, for the duration of any

7 waiting period imposed in the State of new residency

8 for establishing entitlement to such services; and

9 (4) shall provide for the payment for health

10 care services covered under this Act provided to indi11 viduals while temporarily absent from the State

12 based on the following principles:

13 (A) Payment for such health care services

14 is at the rate that is approved by the State pro15 gram in the State in which the services are pro16 vided, unless the States concerned agree to ap17 portion the cost between them in a different

18 manner.

19 (B)(i) Except as provided in clause (ii),

20 payment for such health care services provided

21 outside the United States is made on the basis

22 of the amount that would have been paid by the

23 State program for similar services rendered in

24 the State, with due regard, in the case of hos-
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1 pital services, to the size of the hospital, stand2 ards of service, and other relevant factors.

3 (ii) Payment for services described under

4 clause (i) which are elective services may be

5 subject to prior consent of the agency that ad6 ministers and operates the State program if

7 such elective services are available on a sub8 stantially similar basis in the State.

9 (iii) For the purposes of this subpara10 graph, the term ‘‘elective services’’ means

11 health care services covered under this Act

12 other than services that are provided in an

13 emergency or in any other circumstance in

14 which medical care is required without delay.

15 TITLE II—BENEFITS

16 Subtitle A—Health Care Services

17 SEC. 201. COVERED HEALTH CARE SERVICES.

18 (a) IN GENERAL.—Every eligible individual is enti19 tled to have payment made for the health care services

20 covered under this Act by a participating provider if the

21 service is necessary or appropriate for the maintenance of

22 health or for the diagnosis or treatment of, or rehabilita23 tion following, injury, disability, or disease.
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1 (b) SPECIFIC SERVICES.—Subject to limitations de2 scribed in section 202, health care services covered under

3 this Act are as follows:

4 (1) Inpatient and outpatient hospital care, in5 cluding 24-hour per day emergency services.

6 (2) Diagnostic and screening tests.

7 (3) Medical and other health services furnished

8 by health care professionals who are authorized to

9 provide such services under State law, including

10 medically necessary dental care.

11 (4) Preventive health care, including care for

12 well-defined causes of illness and injury (such as

13 breast, cervical, and colon cancer), immunizations

14 (for children, according to an immunization schedule

15 issued by the American Academy of Pediatrics), pre16 natal and postnatal care (according to guidelines of

17 the American College of Obstetrics and Gynecology,

18 and including prenatal and postnatal care coordina19 tion, and nutrition education), family planning serv20 ices, and well-baby and well-child care (including

21 physical examinations and vision, dental, hearing,

22 and developmental examinations).

23 (5) Prescription drugs, biologicals, and devices.

24 (6) Substance abuse treatment services, includ25 ing comprehensive residential treatment services for
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1 pregnant women and women with children seeking

2 treatment for substance abuse.

3 (7) Inpatient and outpatient mental health

4 services to provide an active preventive, diagnostic,

5 therapeutic, or rehabilitative service with respect to

6 emotional or mental disorders.

7 (8) Hospice care for patients certified to be ter8 minally ill, provided under a State approved pro9 gram.

10 (9) Habilitation and rehabilitation services, in11 cluding physical, speech, and occupational therapies.

12 (10) Home medical equipment and prosthetic

13 devices prescribed by a licensed practitioner.

14 (11) Experimental treatment as deemed nec15 essary by the review of the Board and the State Ad16 visory Boards.

17 SEC. 202. LIMITATIONS AND EXCLUSIONS.

18 (a) NO LIMITS IN GENERAL.—Except as provided in

19 this section, section 203, and section 221, a State program

20 may not limit the amount, duration, or scope of health

21 care services covered under this Act.

22 (b) SPECIFIC EXCLUSIONS.—Health care services ex23 cluded from coverage under this Act include the following:

24 (1) Cosmetic surgery, except medically nec25 essary reconstruction.
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1 (2) Certain amenities in inpatient facilities,

2 such as private rooms and other amenities deter3 mined by the Board, unless medically necessary.

4 SEC. 203. PATIENT COST-SHARING.

5 (a) IN GENERAL.—Except as provided in this section,

6 a State program may not impose cost-sharing for services

7 under this Act.

8 (b) ESTABLISHMENT OF COST-SHARING SCHED9 ULE.—

10 (1) IN GENERAL.—Co-payments and out-of11 pocket limits shall be established by the Board con12 sistent with paragraph (2). The Board shall base its

13 determinations on the following principles:

14 (A) Assurance of administrative simplicity

15 and efficiency.

16 (B) Maintenance of the fiscal integrity of

17 the public health insurance program.

18 (C) Deterrence of unnecessary use of serv19 ices.

20 (D) Encouragement of healthy behaviors.

21 (E) Encouragement of the use of preven22 tive services.

23 (F) Maximization of economic fairness.

24 (G) Minimization of financial barriers to

25 appropriate medical care.
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1 (2) SPECIFICS.—In establishing co-payments

2 and out-of-pocket limits under paragraph (1)—

3 (A) there shall be no cost-sharing imposed

4 with respect to preventive health care (described

5 in section 201(b)(4)), and

6 (B) there shall no deductible for any serv7 ices.

8 (3) STUDIES OF MODIFICATIONS.—

9 (A) IN GENERAL.—The Priorities Council

10 shall study—

11 (i) whether the out-of-pocket limits

12 should be modified to take into account

13 family size and family composition,

14 (ii) whether the use of co-payments is

15 a cost-effective means of containing health

16 care costs and whether the use of co-pay17 ments is an excessive administrative bur18 den on health care providers and fiscal

19 providers (designated under section

20 311(b)(2)),

21 (iii) the effects of the continuation of

22 duplicative private insurance (as allowed in

23 section 602), upon the quality, access, and

24 cost of the public health insurance pro25 gram,
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1 (iv) whether cost sharing require2 ments should be different for individuals

3 that engage in certain practices deemed to

4 increase the likelihood such individuals will

5 utilize more health care resources than in6 dividuals who do not engage in such prac7 tices.

8 (B) SPECIFIC RECOMMENDATIONS.—The

9 Priorities Council within 2 years of the date de10 scribed in section 901(b)(1) shall issue rec11 ommendations regarding the studies described

12 in subparagraph (A). The recommendations

13 must balance the following goals:

14 (i) Preserve the fiscal integrity of the

15 public health insurance program.

16 (ii) Minimize the shifting between in17 dividuals and families of the burden of fi18 nancing the public program.

19 (iii) Encourage behaviors by govern20 ments, intermediaries, providers, and indi21 viduals that lead to reduced costs to the

22 health care system.

23 (3) REGULATIONS BASED ON RECOMMENDA24 TIONS.—
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1 (A) IN GENERAL.—The Board is author2 ized to promulgate regulations, as it deems ap3 propriate, for implementing the recommenda4 tions of the Priorities Council.

5 (B) MODIFICATIONS.—The Board is also

6 authorized to promulgate regulations to make

7 periodic adjustments for inflation to income cat8 egories, co-payments, and deductibles.

9 (C) EFFECT OF REGULATIONS.—The regu10 lations incorporating these modifications to the

11 cost sharing and out-of-pocket limits described

12 in this section shall have the force of law, un13 less within 60 days of the promulgation of the

14 regulations, the Congress enacts a disapproval

15 resolution under the procedures described in

16 section 501.

17 Subtitle B—Long-Term Care

18 Services

19 SEC. 211. COVERED LONG-TERM CARE SERVICES.

20 (a) IN GENERAL.—The Board, by regulation, shall

21 set standards for eligibility, long-term care services cov22 ered, cost-sharing, income protection, and case coordina23 tion, subject to the criteria described in the following sub24 sections.

25 (b) ELIGIBILITY.—
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1 (1) IN GENERAL.—The Board shall determine

2 the standards for eligibility for institutional and for

3 home and community-based long-term care services

4 based on an individual’s ability to perform activities

5 of daily living (ADLs) and instrumental activities of

6 daily living (IADLs), and comparable cognitive or

7 behavioral impairments.

8 (2) DETERMINATION.—Eligibility for long-term

9 care services shall be based on a determination by

10 a case manager of the individual’s ability to perform

11 the minimum level of ADLs and IADLs, according

12 to the standard set by the Board.

13 (3) STANDARD.—The Board shall, pursuant to

14 recommendations by the Advisory Council and the

15 Long-Term Care Services Assessment Commission,

16 periodically make recommendations about the effi17 cacy of using deficits in ADLs and IADLs, or meas18 ures of comparable cognitive or behavioral impair19 ment, or both, to determine eligibility for long-term

20 care services.

21 (c) SERVICES COVERED.—

22 (1) IN GENERAL.—The Board shall determine

23 the long-term care services to be covered under this

24 Act to meet the long-term care needs of the eligible

25 population.
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1 (2) MINIMUM SERVICES.—At a minimum, long2 term care services to be covered under this Act, sub3 ject to standards set by the Board, shall include:

4 (A) Home and community-based services,

5 such as nursing care and rehabilitative and re6 storative care.

7 (B) Nursing home care.

8 (C) Hospice care.

9 (D) Home medical equipment.

10 (E) Services for individuals with devel11 opmental disabilities and mental illness.

12 (d) COST SHARING.—The Board shall establish an

13 income-related cost-sharing schedule for individuals eligi14 ble for long-term care services covered under this Act, tak15 ing into account such factors as what out-of-nursing home

16 expenses would have been.

17 (e) INCOME PROTECTION.—

18 (1) IN GENERAL.—The Board shall reduce the

19 cost sharing to ensure that the income and assets of

20 the individual using long-term care services covered

21 under this Act are sufficient to enable such individ22 ual to retain a personal needs allowance sufficient—

23 (A) to cover all items needed in addition to

24 those provided by the long-term care facility,
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1 (B) to maintain such individual’s primary

2 residence, and

3 (C) to maintain such individual’s independ4 ence once the individual no longer needs long5 term care services.

6 (2) SPOUSAL PROTECTION, ETC.—The Board

7 shall reduce the cost sharing to ensure that the in8 come of the spouse, dependent, parent, or guardian

9 of the individual using long-term care services cov10 ered under this Act is not reduced below levels deter11 mined appropriate by the Board, but in no case less

12 than the spousal protection levels under title XIX of

13 the Social Security Act, as in effect on the day be14 fore the date of the enactment of this Act.

15 (f) CASE MANAGEMENT.—

16 (1) IN GENERAL.—The Board shall set stand17 ards for case coordination of long-term care services

18 covered under this Act.

19 (2) CASE COORDINATOR.—

20 (A) IN GENERAL.—Under the case coordi21 nation system, services shall be made available

22 to individuals through a case coordinator who

23 will be responsible for matching services to each

24 individual’s needs, and coordinating the delivery

25 of services.
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1 (B) SPECIFIC RESPONSIBILITIES.—The

2 specific responsibilities of the case coordinator

3 include:

4 (i) The assessment and periodic reas5 sessment of an individual’s need for serv6 ices, and the availability and efficacy of in7 formal services.

8 (ii) The development of plan of care

9 for the individual.

10 (iii) The authorization and coordina11 tion of services designed to meet an indi12 vidual’s unmet needs.

13 (g) EFFECT OF REGULATIONS.—The regulations in14 corporating the standards described in subsection (a) shall

15 have the force of law, unless within 60 days of the promul16 gation of the regulations, the Congress enacts a dis17 approval resolution under the procedures described in sec18 tion 501.

19 SEC. 212. LONG-TERM CARE SERVICES ASSESSMENT COM20 MISSION.

21 (a) ESTABLISHMENT.—Due to the seriousness of the

22 current problems in long-term care, the Director of the

23 Congressional Office of Technology Assessment (hereafter

24 in this section referred to as the ‘‘Director’’) shall provide

25 for the appointment of a special task force, to be known
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1 as the ‘‘Long-Term Care Services Assessment Commis2 sion’’ (hereafter in this section referred to as the ‘‘Com3 mission’’).

4 (b) MEMBERSHIP.—The Commission shall consist of

5 10 individuals appointed for a seven-year term, beginning

6 on October 1, 1994. The membership of the Commission

7 shall include long-term care service providers, other health

8 and social service professionals, individuals skilled in the

9 conduct and interpretation of biomedical, health services,

10 and health economics research, and representatives of con11 sumers, the elderly, and the disabled. The Director shall

12 fill any vacancy in the membership of the Commission in

13 the same manner as the original appointment. The va14 cancy shall not affect the power of the remaining members

15 to execute the duties of the Commission.

16 (c) COMPENSATION.—All members of the Commis17 sion shall be reimbursed by the Board for travel and per

18 diem in lieu of subsistence expenses during the perform19 ance of duties of the Commission in accordance with sub20 chapter I of chapter 57 of title 5, United States Code.

21 (d) ORGANIZATION.—The Commission shall cease to

22 exist at the end of the 7-year term described in subsection

23 (b).
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1 (e) FACA NOT APPLICABLE.—The provisions of the

2 Federal Advisory Committee Act shall not apply to the

3 Commission.

4 (f) DUTIES.—

5 (1) IN GENERAL.—The Commission shall make

6 recommendations to the Board not later than Janu7 ary 31 of 1995 (and of each subsequent year) re8 garding—

9 (A) the adequacy and appropriateness of

10 the long-term care services covered under this

11 Act,

12 (B) the criteria for eligibility for long-term

13 care services,

14 (C) the effect of the cost sharing require15 ments for long-term care services,

16 (D) the financial protections provided indi17 viduals in the use of such services and the abil18 ity of the patient and any spouse, dependent,

19 parent, or guardian of the patient in the com20 munity to remain financially independent once

21 the patient no longer needs long-term care serv22 ices,

23 (E) the effect of the long-term care serv24 ices covered under this Act on the availability
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1 and use of informal long-term care services and

2 private long-term care insurance, and

3 (F) the overall functioning of the provision

4 of long-term care services covered under this

5 Act, once fully implemented.

6 (2) REVIEW.—The Commission shall review and

7 analyze any long-term care services regulations or

8 proposed regulations of the Board and report to the

9 Congress its assessment of the appropriateness of

10 the regulations in meeting the statutory criteria es11 tablished under this Act.

12 (g) AUTHORIZATION OF APPROPRIATIONS.—There

13 are authorized to be appropriated such sums as are nec14 essary for the establishment and operation of the Commis15 sion to carry out the purposes of this Act.

16 Subtitle C—Modification of

17 Services

18 SEC. 221. MODIFICATION OF SERVICES COVERED UNDER

19 THIS ACT.

20 (a) RECOMMENDATIONS BY PRIORITIES COUNCIL.—

21 Not later than January 31 of 1998 (and of each subse22 quent year), the Priorities Council shall issue a report to

23 the Board describing any changes, additions, deletions, or

24 clarifications the Priority Council recommends for the
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1 health care services and long-term care services covered

2 under this Act.

3 (b) BOARD REGULATIONS.—

4 (1) IN GENERAL.—The Board is authorized to

5 promulgate regulations, as the Board deems appro6 priate, for implementing the recommendations of the

7 Priorities Council. Such regulations are to be pro8 mulgated within 1 year of the submission of the Pri9 orities Council’s report.

10 (2) EFFECT.—The regulations incorporating

11 modifications in the health care services and long12 term care services covered under this Act shall have

13 the force of law, unless within 60 days of the pro14 mulgation of the regulations, the Congress enacts a

15 disapproval resolution under the procedures de16 scribed in section 501.

17 TITLE III—FEDERAL AND STATE

18 ADMINISTRATION

19 Subtitle A—Federal Administration

20 SEC. 301. FEDERAL HEALTH BOARD.

21 (a) IN GENERAL.—There is hereby established a

22 Federal Health Board.

23 (b) APPOINTMENT AND TERMS OF MEMBERS.—

24 (1) APPOINTMENT.—The Board shall be com25 posed of 9 individuals appointed by the President,
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1 with the advice and consent of the Senate, not later

2 than October 1, 1994, and shall be chosen on the

3 basis of backgrounds in health policy, health eco4 nomics, the healing professions, and the administra5 tion of health care institutions. At least 1 member

6 of the Board shall represent consumer interests, and

7 due regard must be given to geographic, urban, and

8 rural representation. No more than 5 members may

9 be affiliated with a single political party.

10 (2) TERMS OF MEMBERS.—The individuals ap11 pointed shall serve for a term of 9 years (or until

12 a successor is appointed), except that the terms of

13 individuals initially appointed shall be (as specified

14 by the President) for such fewer number of years as

15 will provide for the expiration of terms on a stag16 gered basis.

17 (3) REMOVAL FOR CAUSE ONLY.—Upon con18 firmation, members of the Board may not be re19 moved except for cause upon notice and hearing.

20 (c) VACANCIES.—

21 (1) IN GENERAL.—The President shall fill any

22 vacancy in the membership of the Board in the same

23 manner as the original appointment. The vacancy

24 shall not affect the power of the remaining members

25 to execute the duties of the Board.
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1 (2) VACANCY APPOINTMENTS.—Any member

2 appointed to fill a vacancy shall serve for the re3 mainder of the term for which the predecessor of the

4 member was appointed.

5 (3) REAPPOINTMENT.—The President may re6 appoint an appointed member of the Board for a

7 second term in the same manner as the original ap8 pointment.

9 (d) CHAIRPERSON AND VICE CHAIRPERSON.—The

10 Board shall select a Chairperson and a Vice Chairperson

11 from among the members of the Board.

12 (e) COMPENSATION.—Members of the Board shall be

13 compensated at a level comparable to level II of the Execu14 tive Schedule, in accordance with section 5313 of title 5,

15 United States Code.

16 (f) STAFF.—The Board shall employ such staff as the

17 Board may determine necessary.

18 (g) APPLICABILITY OF CIVIL SERVICE PROVI19 SIONS.—The staff of the Board may be appointed without

20 regard to the provisions of title 5, United States Code,

21 governing appointments in the competitive service and be

22 compensated without regard to the provisions of chapter

23 51, and subchapter III of chapter 53 of title 5 relating

24 to classification and General Schedule pay rates, except

25 that no individual may receive pay less than 120 percent
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1 of the minimum rate of basic pay payable for GS–15 of

2 the General Schedule or more than the rate of basic pay

3 payable for level IV of the Executive Schedule.

4 (h) DUTIES.—

5 (1) IN GENERAL.—The Board is responsible for

6 the overall administration of this Act, including such

7 duties specifically designated by this Act.

8 (2) ADDITIONAL DUTIES.—The duties of the

9 Board also include—

10 (A) facilitating the exchange of informa11 tion among States,

12 (B) establishing, evaluating, and updating

13 national minimum quality standards,

14 (C) establishing uniform reporting require15 ments,

16 (D) developing a uniform claims form,

17 (E) reviewing and approving interstate

18 consortia,

19 (F) assisting States in developing systems

20 to minimize fragmented care, and

21 (G) developing and evaluating activities

22 combating fraud and abuse within the health

23 care system.

24 (i) REPORTS.—
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1 (1) INITIAL REPORT.—Not later than January

2 1, 1996, the Board shall report to the Congress re3 garding the implementation of the program estab4 lished under this Act, including any recommenda5 tions for further implementing legislation.

6 (2) ANNUAL REPORTS.—Beginning January 1,

7 1997, the Board shall annually report to Congress

8 on the status of expenditures under this Act and the

9 long-range plans and goals of the Board for the or10 ganization and delivery of health care services and

11 long-term care services under this Act.

12 SEC. 302. FEDERAL HEALTH ADVISORY COUNCIL.

13 (a) APPOINTMENT.—Not later than January 1, 1995,

14 the Board shall provide for appointment of a Federal

15 Health Advisory Council to advise the Board on its activi16 ties.

17 (b) MEMBERSHIP.—Such Advisory Council shall con18 sist of 15 members who are representatives of consumers,

19 providers, unions, health care experts, senior citizen

20 groups, public health officials, experts in long-term care,

21 rural health care and mental illness, and other individuals

22 with an interest in the health care system. Such members

23 shall serve for terms of 3 years, except that, in the initial

24 appointment, 5 members shall be each appointed for terms

25 of 1-year, 2-years, and 3-years.
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1 (c) VACANCIES.—

2 (1) IN GENERAL.—The Board shall fill any va3 cancy in the membership of the Advisory Council in

4 the same manner as the original appointment. The

5 vacancy shall not affect the power of the remaining

6 members to execute the duties of the Advisory Coun7 cil.

8 (2) VACANCY APPOINTMENTS.—Any member

9 appointed to fill a vacancy shall serve for the re10 mainder of the term for which the predecessor of the

11 member was appointed.

12 (3) REAPPOINTMENT.—The Board may re13 appoint an appointed member of the Advisory Coun14 cil for a second term in the same manner as the

15 original appointment.

16 (d) CHAIRPERSON AND VICE CHAIRPERSON.—The

17 Advisory Council shall select a Chairperson and a Vice

18 Chairperson from among the members of the Advisory

19 Council.

20 (e) COMPENSATION.—All members of the Advisory

21 Council shall be reimbursed by the Board for travel and

22 per diem in lieu of subsistence expenses during the per23 formance of duties of the Advisory Council in accordance

24 with subchapter I of chapter 57 of title 5, United States

25 Code.
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1 (f) FACA NOT APPLICABLE.—The provisions of the

2 Federal Advisory Committee Act shall not apply to the

3 Advisory Council.

4 (g) DUTIES.—The Advisory Council shall conduct

5 studies and make recommendations to the Board on the

6 overall functioning of the program established under this

7 Act and consumer and provider satisfaction with such pro8 gram.

9 SEC. 303. FEDERAL HEALTH PRIORITIES COUNCIL.

10 (a) IN GENERAL.—There is hereby established a

11 Federal Health Priorities Council.

12 (b) APPOINTMENT AND TERMS OF MEMBERS.—

13 (1) APPOINTMENT.—The Priorities Council

14 shall be composed of 15 individuals appointed by the

15 President, with the advice and consent of the Sen16 ate, not later than October 1, 1994. Such individuals

17 shall be representatives from the fields of medicine,

18 dentistry, mental health care, nursing, social serv19 ices, ethics, economics, business, and consumer

20 groups.

21 (2) TERMS OF MEMBERS.—The individuals ap22 pointed shall serve for a term of 5 years, except that

23 the terms of individuals initially appointed shall be

24 (as specified by the President) for such fewer num-
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1 ber of years as will provide for the expiration of

2 terms on a staggered basis.

3 (c) VACANCIES.—

4 (1) IN GENERAL.—The President shall fill any

5 vacancy in the membership of the Priorities Council

6 in the same manner as the original appointment.

7 The vacancy shall not affect the power of the re8 maining members to execute the duties of the Prior9 ities Council.

10 (2) VACANCY APPOINTMENTS.—Any member

11 appointed to fill a vacancy shall serve for the re12 mainder of the term for which the predecessor of the

13 member was appointed.

14 (3) REAPPOINTMENT.—The President may re15 appoint an appointed member of the Priorities

16 Council for a second term in the same manner as

17 the original appointment.

18 (d) PRESIDENT AND VICE PRESIDENT.—The Prior19 ities Council shall select a President and a Vice President

20 from among the members of the Priorities Council.

21 (e) COMPENSATION.—Members of the Priorities

22 Council shall be compensated at a level comparable to level

23 II of the Executive Schedule, in accordance with section

24 5313 of title 5, United States Code.
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1 (f) STAFF.—The Priorities Council shall employ such

2 staff as the Priorities Council may determine necessary.

3 (g) APPLICABILITY OF CIVIL SERVICE PROVI4 SIONS.—The staff of the Priorities Council may be ap5 pointed without regard to the provisions of title 5, United

6 States Code, governing appointments in the competitive

7 service and be compensated without regard to the provi8 sions of chapter 51, and subchapter III of chapter 53 of

9 title 5 relating to classification and General Schedule pay

10 rates, except that no individual may receive pay less than

11 120 percent of the minimum rate of basic pay payable for

12 GS–15 of the General Schedule or more than the rate of

13 basic pay payable for level IV of the Executive Schedule.

14 (h) COMMITTEES.—The Priorities Council may estab15 lish such committees of its members and other medical,

16 economic, or health services advisers as it determines to

17 be necessary to assist the Priorities Council in the per18 formance of its duties.

19 (i) FUNCTIONS.—In order to build a consensus on the

20 values to be used to guide health resource decisions, the

21 Priorities Council shall have the following functions:

22 (1) Conduct public hearings and solicit testi23 mony and information from advocates for children,

24 senior citizens, the disabled, consumers of mental
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1 health services, low-income people, providers of

2 health care, business leaders, and others.

3 (2) Building on outcomes research and the de4 velopment of practice guidelines, conduct studies and

5 make recommendations for how health care dollars

6 should be allocated in the context of a publicly fund7 ed national health insurance plan.

8 (j) REPORTS.—The Priorities Council shall report to

9 the Board a list of health services ranked by priority, from

10 the most important to the least important, representing

11 the comparative benefits of each service to the Nation’s

12 population. The recommendation shall be accompanied by

13 a report of an independent actuary retained for the Board

14 to determine rates necessary to cover the costs of the in15 cluded services in order to establish an appropriate annual

16 global budget. The recommendation is to be used in evalu17 ating and modifying the health care services and the long18 term care services covered under this Act. The reports

19 from the Priorities Council to the Board are to be submit20 ted by January 31 of 1996 (and of each subsequent year),

21 to be acted on by the Board by the following January 31.

22 SEC. 304. AUTHORIZATION OF APPROPRIATIONS.

23 There are authorized to be appropriated such sums

24 as are necessary for the establishment and operation of
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1 the Board, Advisory Council, and Priorities Council to

2 carry out the purposes of this Act.

3 Subtitle B—State Administration

4 SEC. 311. STATE PROGRAMS.

5 (a) SUBMISSION OF PROGRAMS.—

6 (1) IN GENERAL.—Not later than October 1,

7 1996, each State shall submit to the Board the

8 State program in the State.

9 (2) REGIONAL PROGRAMS.—Any State may join

10 with neighboring States to submit to the Board a re11 gional program in lieu of a State program, as de12 scribed in section 314.

13 (b) REVIEW AND APPROVAL OF PROGRAMS.—The

14 Board shall review programs submitted under subsection

15 (a) and determine whether such programs meet the re16 quirements for approval, not later than October 1, 1997.

17 The Board shall not approve such a program unless it

18 finds that the program provides, consistent with the provi19 sions of this Act, for—

20 (1) adequate financing of health care services

21 and long-term care services covered under this Act

22 through a designated fund, including the annual

23 submission of the State program budget to the

24 Board,
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1 (2) adequate administration, including the des2 ignation of a single nonprofit State agency respon3 sible for administration of the program, and suffi4 cient provisions to ensure against fraud and abuse,

5 (3) the establishment of—

6 (A) an institution reimbursement negotia7 tion board to negotiate global operating, capital,

8 and health training budgets with hospitals and

9 other health care and long-term care institu10 tions,

11 (B) a practitioner reimbursement negotia12 tion board (with membership including State

13 government representatives, consumers, general

14 practice physicians, specialists, and

15 nonphysician practitioners) to negotiate reim16 bursement rates for participating providers, and

17 (C) at the State’s option, a State advisory

18 board (with broad representation of health pol19 icy experts, institutional providers, practition20 ers, and consumers) to generally oversee and re21 view the performance of the State program,

22 (4) assurances that individuals have the free23 dom to choose practitioners and other health care

24 providers for services covered under this Act, and
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1 (5) an organized grievance procedure available

2 to consumers through which complaints about the

3 organization and administration of the State pro4 gram may be filed, heard, and resolved.

5 (c) OPERATIONAL STATUS.—A State program in a

6 State shall not be considered operational unless it is ap7 proved and remains approved under subsection (b).

8 (d) FAILURE TO COMPLY WITH THIS ACT.—When9 ever the Board, after reasonable notice and opportunity

10 for hearing to the designated State agency finds that in

11 the administration of the State program there is a failure

12 to comply with any provision of this Act, the Board may—

13 (1) withhold further payments to the State

14 under section 402 and may limit such withholding to

15 specific portions of such program affected by the

16 failure, or

17 (2) place the State program, or specific portions

18 of such program, in receivership under the jurisdic19 tion of the Board,

20 until such failure has been corrected.

21 (e) JUDICIAL REVIEW.—

22 (1) IN GENERAL.—If any State is dissatisfied

23 with the Board’s action in denying approval of such

24 State’s program or finding a failure under sub25 section (d) with respect to such program, such State
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1 may, within 60 days after notice of such action, file

2 with the United States court of appeals for the cir3 cuit in which such State is located a petition for re4 view of that action. A copy of the petition shall be

5 forthwith transmitted by the clerk of the court to

6 the Board. The Board thereupon shall file in the

7 court the record of the proceedings upon which the

8 Board’s action was based, as provided in section

9 2112 of title 28, United States Code.

10 (2) FINDINGS OF FACT.—The findings of fact

11 by the Board, if supported by substantial evidence,

12 shall be conclusive; but the court, for good cause

13 shown, may remand the case to the Board to take

14 further evidence, and the Board may thereupon

15 make new or modified findings of fact and may mod16 ify the Board’s previous action, and shall file in the

17 court the record of the further proceedings. Such

18 new or modified findings of fact shall likewise be

19 conclusive if supported by substantial evidence.

20 (3) JURISDICTION OF COURT.—Upon the filing

21 of such petition, the court shall have jurisdiction to

22 affirm the action of the Board or to set it aside, in

23 whole or in part. The judgment of the court shall be

24 subject to review by the Supreme Court of the Unit-
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1 ed States upon certiorari or certification as provided

2 in section 1254 of title 28, United States Code.

3 SEC. 312. USE OF FISCAL INTERMEDIARIES.

4 (a) IN GENERAL.—Each State program may contract

5 with fiscal intermediaries in a process of competitive bid6 ding.

7 (b) ROLE OF FISCAL INTERMEDIARY.—

8 (1) IN GENERAL.—Subject to paragraph (2)

9 and under continuous State oversight, the fiscal

10 intermediary shall process claims and reimburse11 ments, distribute the allocation of funds as specified

12 in agreements on global operating budgets, and as13 sume general responsibility for the administration of

14 the State program.

15 (2) LIMITATION.—The fiscal intermediary may

16 not participate in, nor administer, the negotiating

17 processes used to establish global operating budgets

18 or practitioner reimbursement rates.

19 (c) TYPE OF ORGANIZATION.—The fiscal

20 intermediary may be any type of entity designated by the

21 State, including nonprofit associations and private compa22 nies, as long as the State or regional program provides

23 for public accountability. Such accountability may include

24 review of the operations of the fiscal intermediary by the

25 State advisory board.
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1 SEC. 313. STATE WAIVERS; MANAGED CARE.

2 (a) STATE WAIVERS.—A State program shall be al3 lowed to obtain waivers from the Board—

4 (1) to implement alternative and innovative—

5 (A) methods of reimbursing health care

6 providers,

7 (B) patient cost-sharing arrangements,

8 and

9 (C) administrative structures, and

10 (2) to provide the services covered under this

11 Act through the use of health plans paid through a

12 capitation method in order to allow the freedom of

13 choice of all eligible individuals in the selection of a

14 health plan.

15 In approving any waiver the Board shall assure itself that

16 the State program otherwise complies with the require17 ments of this Act that are not inconsistent with the grant18 ing of such waiver.

19 (b) MANAGED CARE OPTION.—No provision of this

20 Act shall be construed to prohibit or discourage any State

21 from developing, or contracting with, managed care net22 works for the purpose of delivering services covered under

23 this Act of a higher quality and in a more cost-effective

24 manner, as long as such networks otherwise meet the re25 quirements of this Act.
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1 (c) ORGANIZED APPROACHES TO DELIVERY OF

2 SERVICES.—The Board shall sponsor efforts to encourage

3 States and providers of services to develop and expand or4 ganized approaches to the delivery of health care services

5 covered under this Act, including health maintenance or6 ganizations, hospital-based and community-oriented team

7 health services, and neighborhood-hospital-home health

8 care plans.

9 SEC. 314. STATE REGIONAL CONSORTIA.

10 (a) IN GENERAL.—Any group of States may enter

11 into an agreement to establish a regional consortium for

12 the purposes of implementing a program to be approved

13 by the Board under section 311. Such regional consortium

14 shall have jurisdiction over all States that are parties to

15 such agreement and that shall be subject to the provisions

16 of section 311 as if such consortium were established by

17 a single State.

18 (b) CONSORTIUM AGREEMENT.—Any agreement to

19 establish a State regional consortium shall, in addition to

20 providing for the requirements specified in section 311(b),

21 provide for—

22 (1) a mechanism to resolve any disputes be23 tween or among the States that are parties to the

24 agreement, and
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1 (2) the collection of data and information con2 cerning the operations of the consortium and the

3 submission of such data and information to the

4 Board on an annual basis.

5 (c) CONGRESSIONAL REVIEW.—Any consortium

6 agreement described in this section which has been ap7 proved by the Board, shall be submitted to the Congress

8 and shall be considered in effect, unless within 60 days

9 of the submission of the agreement, the Congress enacts

10 a disapproval resolution under the procedures described

11 in section 501.

12 SEC. 315. GRANTS TO STATES.

13 (a) IN GENERAL.—The Board shall make grants (in14 cluding cooperative agreements) available to States for

15 funding programs and for research designed to prevent or

16 minimize the high costs of health care, to treat illness,

17 disease, or medical conditions created by conditions in the

18 environment or workplace, and to promote health and

19 wellness.

20 (b) SPECIFIC PROGRAM AREAS.—Grants under this

21 section shall be awarded for initiatives in the areas of—

22 (1) environmental health, and

23 (2) health promotion and disease prevention.
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1 (c) REQUESTS FOR PROPOSALS.—The Board shall

2 issue periodic requests each year for proposals for grants

3 under this section.

4 SEC. 316. TECHNICAL ASSISTANCE TO STATES.

5 (a) GRANTS.—

6 (1) IN GENERAL.—Not later than October 1,

7 1995, the Board shall award a grant to each State

8 or group of States to assist in paying the costs asso9 ciated with the establishment and initial operation of

10 the State plan or the State regional consortium

11 agreement.

12 (2) AMOUNTS.—Not less than $500,000 shall

13 be provided to each State or group of States under

14 a grant awarded under paragraph (1), and any

15 State or group of States shall remit to the Trust

16 Fund any unspent amount of such grant at the end

17 of the 2-year period beginning with the date of the

18 awarding of such grant.

19 (3) PLANNING FUNCTIONS.—Amounts provided

20 under grants awarded under paragraph (1) shall be

21 utilized for planning functions only.

22 (4) STUDY.—Not later than October 1, 1998,

23 the Board shall prepare and submit to the appro24 priate committees of Congress, a report that shall

25 contain the results of a study conducted by the
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1 Board concerning the use of the grants awarded

2 under paragraph (1), and whether such use was ef3 fective preparing State plans and State regional con4 sortia agreements and simplifying administrative

5 procedures.

6 (b) TECHNICAL ASSISTANCE.—The Board shall pro7 vide technical assistance to States in developing State

8 plans and State regional consortia agreements.

9 (c) AUTHORIZATION OF APPROPRIATIONS.—There

10 are authorized to be appropriated such sums as may be

11 necessary to carry out this section.

12 TITLE IV—FINANCING

13 Subtitle A—Health Budgets

14 SEC. 401. NATIONAL HEALTH BUDGET.

15 (a) IN GENERAL.—

16 (1) ANNUAL BUDGETS.—Except as provided in

17 paragraph (2), the Board shall establish an annual

18 fiscal year budget of expenditures that estimates the

19 total expenditures to be made in such fiscal year by

20 the Federal Government and States for health care

21 services and long-term care services covered under

22 this Act, including the administrative costs associ23 ated with such services.
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1 (2) BIENNIAL BUDGETS.—The Board may es2 tablish biennial fiscal year budgets in lieu of annual

3 budgets.

4 (b) NATIONAL AVERAGE PER CAPITA COSTS.—

5 (1) IN GENERAL.—At least 6 months before the

6 beginning of the first fiscal year of the program

7 under this Act, the Board shall compute the national

8 average per capita cost for each of the services de9 scribed in subsection (a) using data the Board

10 deems to be appropriate.

11 (2) ADJUSTMENTS FOR RISK GROUPS.—

12 (A) IN GENERAL.—The Board shall de13 velop an adjustment factor to the national aver14 age per capita costs computed under paragraph

15 (1) for each risk group (as designated under

16 subparagraph (B)) to reflect the national aver17 age per capita costs for that risk group.

18 (B) RISK GROUPS.—The Board shall des19 ignate a series of risk groups, determined by

20 age, sex, and other factors that represent dis21 tinct patterns of health care services and long22 term care services utilization and costs.

23 (3) STATE ADJUSTMENTS TO NATIONAL AVER24 AGE PER CAPITA COSTS.—The Board shall develop
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1 for each State a factor to adjust the national aver2 age per capita costs for each risk group to reflect—

3 (A) average labor and nonlabor costs that

4 are necessary to produce the services described

5 in subsection (a),

6 (B) any special social, environmental, epi7 demiological, or other condition affecting health

8 status or the need for health care services and

9 long-term care services,

10 (C) the geographic distribution of the

11 State’s population, particularly the proportion

12 of the population residing in rural or medically

13 underserved areas,

14 (D) the quality and availability of the

15 State’s existing health care resources needed for

16 delivering health care services and long-term

17 care services, and

18 (E) any other economic, geographic, and

19 sociologic factors.

20 (c) STATE TOTAL EXPENDITURES.—The Board shall

21 compute for each State total projected expenditures in the

22 next fiscal year for each of the services described in sub23 section (a), by multiplying—

24 (1) the national average per capita costs of each

25 risk group designated in subsection (b)(2)(B), by
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1 (2) the product of the State adjustment factors

2 described in subsection (b)(3) and the number of

3 persons in the State estimated by the Bureau of the

4 Census to be resident members of each risk group

5 at the beginning of the next fiscal year.

6 (d) FEDERAL CONTRIBUTIONS.—

7 (1) IN GENERAL.—The Board shall determine

8 the appropriate Federal contribution for each State,

9 constituting the Federal percentage share of each

10 State’s total projected expenditures for the services

11 described in section (a). The Federal share shall be

12 determined by subtracting the State share from 100

13 percent of the total projected expenditures for such

14 State (as described under subsection (c)), but in no

15 event shall such Federal contribution be less than 75

16 percent nor more than 85 percent of such expendi17 tures. The Federal share for all States shall equal

18 80 percent of the aggregate of such expenditures for

19 all States.

20 (2) ADJUSTMENTS IN STATE SHARE.—In deter21 mining each State share, the Board shall develop a

22 formula that considers a State’s—

23 (A) per capita income,

24 (B) total taxable resources,
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1 (C) economic performance relative to the

2 national economy as it affects the availability of

3 taxable resources, and

4 (D) other relevant economic and demo5 graphic indicators.

6 (e) SUBSEQUENT CALCULATIONS.—For each subse7 quent fiscal year, the Board shall recompute under sub8 sections (a), (b), (c), and (d) at least 6 months before the

9 beginning of such fiscal year. In making such a recom10 putation, the Board shall take into account—

11 (1) changes in medical technology, outcomes re12 search evidence concerning the efficacy and safety of

13 health care services and long-term care services,

14 needs for health personnel, professional practice

15 guidelines, and changing health care priorities, after

16 reviewing recommendations of the Advisory Council

17 and the Priorities Council, and

18 (2) changes in the services described in sub19 section (a) under regulations promulgated by the

20 Board and accepted by the Congress under section

21 204.

22 (f) EFFECT OF BOARD ACTIONS.—Any determina23 tion made by the Board under this section with respect

24 to any fiscal year shall be submitted to the Congress at

25 least 6 months before the beginning of such fiscal year,
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1 and shall have the force of law, unless within 60 days of

2 the submission of such determination, the Congress enacts

3 a disapproval resolution under the procedures described

4 in section 501.

5 SEC. 402. PAYMENTS TO STATES.

6 (a) IN GENERAL.—For each fiscal year, each State

7 with a State program approved under section 311, is enti8 tled to receive (subject to section 311(d)), from amounts

9 in the Trust Fund, a Federal contribution in an amount

10 equal to the product of—

11 (1) the Federal share for such State (computed

12 under section 401(d), and

13 (2) such State’s total projected expenditures

14 (computed under section 401(c)).

15 (b) USE OF DEDICATED FUNDS.—

16 (1) IN GENERAL.—All revenues, including the

17 Federal contribution and State revenues provided to

18 finance a State program under this Act shall be allo19 cated to a dedicated fund specified by the State.

20 Payments for health care services and long-term

21 care services covered under this Act shall be made

22 from such fund.

23 (2) SPECIAL ACCOUNTS.—Each State shall es24 tablish within its designated fund special accounts,

25 the amount of revenues deposited in each to be de-
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1 termined by the State. The various special accounts

2 shall include the following:

3 (A) An Institutional Global Operating

4 Budget Account shall be used to fund total ex5 penditures for the operating costs of hospitals

6 and other health care and long-term care insti7 tutions, allocated according to the method spec8 ified in section 411(b).

9 (B) An Institutional Capital Account shall

10 be used to fund total expenditures for capital11 related items in hospitals and other health care

12 and long-term care institutions, allocated ac13 cording to the method specified in section

14 411(c).

15 (C) A Health Training Account shall be

16 used to fund direct and indirect graduate medi17 cal education in hospitals and other health care

18 and long-term care institutions to cover excess

19 operating and capital costs associated with

20 teaching and related research activities, allo21 cated according to the method specified in sec22 tion 411(d).

23 (D) A Practitioner Reimbursement Ac24 count shall be used to fund the reimbursement

25 of services provided by health care practitioners,
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1 allocated according to the method specified in

2 section 412.

3 SEC. 403. STATE PROGRAM BUDGETS.

4 (a) IN GENERAL.—Each State program shall estab5 lish an annual fiscal year State program budget which pro6 vides for—

7 (1) the total expenditures to be made under the

8 State program in such fiscal year for health care

9 services and long-term care services covered under

10 this Act (including administrative and associated

11 costs), and

12 (2) the revenues to meet such expenditures.

13 (b) COORDINATION.—Each State program budget

14 shall be coordinated, in a manner specified by the Board,

15 with the national health budget established under section

16 401(a).

17 (c) STATE SHARE.—

18 (1) IN GENERAL.—Each State program shall

19 cover the State share of program costs through the

20 use of tax revenues and other financing methods al21 lowed under section 424.

22 (2) ADDITIONS TO STATE SHARE.—Each State

23 shall raise the revenues necessary to cover at least

24 the State share specified in the national health

25 budget established by the Board (computed under
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1 section 401(d)). Each State is permitted to raise ad2 ditional revenues and to increase such State’s health

3 program expenditures beyond the amount specified

4 in the State share specified for the national health

5 budget—

6 (A) to cover the costs of benefits for health

7 care services or long-term care services the

8 State program authorizes in addition to the

9 services covered in this Act or as amended by

10 the Board and the Congress,

11 (B) to provide for increased global operat12 ing, capital, or health training budgets for hos13 pitals and other health care and long-term care

14 institutions,

15 (C) to provide for any unexpected increase

16 in health care costs identified by the State pro17 gram, and

18 (D) for other purposes that may be identi19 fied by the Board.

20 (d) BARRIERS TO ACCESS PROHIBITED.—No State,

21 either by intention or as an unstated consequence of budg22 et allocations, may restrict or cause to be restricted timely

23 access to the medically necessary and appropriate health

24 care services and long-term care services covered under
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1 this Act, or permit queues for services to form that have

2 the potential of being life threatening.

3 (e) ANNUAL PUBLICATION.—The State program

4 shall provide for the publication annually of the most re5 cent State program budget established under this section.

6 Subtitle B—Payments to Providers

7 SEC. 411. PAYMENTS TO HOSPITALS AND OTHER HEALTH

8 CARE AND LONG-TERM CARE INSTITUTIONS.

9 (a) IN GENERAL.—Each State program shall be re10 sponsible for—

11 (1) allocating from the State program budget

12 the aggregate amount of money to be directed to

13 hospitals and other health care and long-term care

14 institutions for the global operating, capital, and

15 health training budgets of such institutions, and

16 (2) devising mechanisms for the allocation from

17 such budget of capital expenditures in non-institu18 tional settings.

19 (b) GLOBAL BUDGETS FOR OPERATING EXPENSES

20 FOR HOSPITALS AND OTHER HEALTH CARE AND LONG21 TERM CARE INSTITUTIONS.—The following principles

22 shall guide a State institution reimbursement negotiation

23 board in negotiating institutional global operating budg24 ets:
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1 (1) Each State program budget shall include a

2 separate account for global operating expenses to

3 provide for total State expenditures for the operat4 ing expenses of hospitals and other health care and

5 long-term care institutions.

6 (2) Payment shall be based on an annual pro7 spective global budget for operating expenses sub8 mitted by an institution, in a manner specified by

9 the State program, to the agency designated by the

10 State program.

11 (3) The budgets shall take into account

12 amounts that are reasonable and necessary in the ef13 ficient provision of necessary hospital and other in14 stitutional services covered under this Act.

15 (4) The operating budgets shall not include

16 capital-related and health training expenses.

17 (5) Adjustments may later be made in the

18 budget to reflect significant changes in the volume

19 or types of services assumed in the approval of the

20 budget.

21 (6) A State should encourage innovation by per22 mitting any institution to include in its budget for

23 the immediate year any programs designed to in24 crease efficiency in later years, if those improve-
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•HR 1691 IH

1 ments can be demonstrated to the satisfaction of the

2 designated State agency.

3 (c) CAPITAL BUDGETS FOR HOSPITALS AND OTHER

4 HEALTH CARE AND LONG-TERM CARE INSTITUTIONS.—

5 The following principles shall guide a State institution re6 imbursement negotiation board in negotiating institutional

7 capital budgets:

8 (1) Each State program budget shall include a

9 separate account for capital expenses to provide for

10 total State expenditures for the capital-related items

11 in hospitals and other health care and long-term

12 care institutions.

13 (2) Each State program budget shall specify

14 the general manner in which such expenditures for

15 capital-related items are to be distributed among dif16 ferent types of institutions and the different areas of

17 the State to take into account the need for capital

18 expenditures throughout the State.

19 (3) Capital expenditures are those authorized

20 by the State for the provision of insured health serv21 ices, regardless of whether the source of funds for

22 the capital expenditure is derived from accumulated

23 depreciation charges, operating surpluses or retained

24 earnings, expenditure of accumulated fund balances,

25 issuance of bonds, notes, debentures or other evi-
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1 dence of indebtedness, borrowed funds, or any other

2 source including equity capitalization.

3 (4) Unless otherwise provided in this Act re4 garding underserved areas, or waived by the des5 ignated State agency if necessary to provide equi6 table resource allocation and access to quality care,

7 hospitals and other health care and long-term care

8 institutions shall furnish a 15 percent match for

9 funds allocated from the Institutional Capital Ac10 count of the budget.

11 (d) HEALTH TRAINING FOR HOSPITALS AND OTHER

12 HEALTH CARE AND LONG-TERM CARE INSTITUTIONS.—

13 The following principles shall guide a State institution re14 imbursement negotiation board in negotiating institutional

15 health training budgets:

16 (1) Each State program budget shall include a

17 separate account for direct and indirect graduate

18 medical education-related expenses in hospitals and

19 other health care and long-term care institutions.

20 (2) Each state program budget shall specify the

21 general manner in which such expenditures for di22 rect and indirect graduate medical education are to

23 be distributed among different types of institutions

24 and the different areas of the State.
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1 (3) The distribution of funds to hospitals and

2 other health care and long-term care institutions

3 from the Health Training Account must conform to

4 the following principles:

5 (A) At least 50 percent of the funding

6 from the Health Training Account is to be di7 rected to primary care training programs.

8 (B) For each 5-year period beginning after

9 the date which is 5 years after the date of the

10 enactment of this Act, the Advisory Board will

11 evaluate the required minimum percentage of

12 funds that States must direct to primary care

13 and recommend whether the percentage should

14 be changed to ensure consistency with the goal

15 of encouraging primary care residency training

16 programs.

17 (C) The State is to develop a methodology

18 for funding nonhospital-based residency pro19 grams and to establish opportunities for

20 residencies in community-based health care fa21 cilities.

22 (D) The distribution of funds from the

23 Health Training Account must take into ac24 count the potentially higher costs of placing

25 medical students in rural residency programs.
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1 (E) The distribution of funds from the

2 Health Training Account must accommodate

3 the education and training needs of

4 nonphysician practitioners.

5 SEC. 412. PAYMENTS FOR PRACTITIONERS SERVICES.

6 The State practitioner reimbursement negotiation

7 board shall negotiate with the State organizations rep8 resenting each of the practitioner disciplines in order to

9 derive a relative value scale fee schedule that fulfills each

10 of the following principles:

11 (1) Appropriate levels of payment are provided

12 primary care services, including general, family, and

13 preventive procedures.

14 (2) The same compensation is given for the

15 same procedures even when performed by different

16 types of practitioners licensed to offer those proce17 dures.

18 (3) Reimbursement rates for different proce19 dures performed by practitioners in different dis20 ciplines reflect the relative value of those procedures.

21 (4) Urban and rural practitioners receive the

22 same reimbursement rates for the same services, un23 less the State determines that a differential rate is

24 required to increase the access to health care practi25 tioners in underserved areas.
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1 (5) A process is established that keeps overall

2 reimbursements in line with the amount of funding

3 budgeted for practitioner reimbursements.

4 SEC. 413. SPECIAL NONPHYSICIAN PRACTITIONER PROVI5 SIONS.

6 The following principles shall guide the State practi7 tioner reimbursement negotiation board in negotiating re8 imbursement rates for nonphysician practitioners:

9 (1) When the same services covered under this

10 Act are provided by practitioners licensed by the

11 State, reimbursement rates for those same services

12 shall be the same regardless of the type of practi13 tioner providing such services.

14 (2) For procedures covered under this Act,

15 services provided by all practitioners licensed in the

16 State for those services are to be included in the re17 imbursement fee schedule.

18 SEC. 414. MANDATORY ASSIGNMENT.

19 (a) IN GENERAL.—Except with respect to patient

20 cost-sharing provisions under section 203 of this Act, no

21 individual shall be liable for payment of any amount for

22 health care services or long-term care services covered

23 under this Act, and payment by a State program shall con24 stitute payment in full for such services.
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1 (b) ENFORCEMENT.—The State program shall apply

2 appropriate sanctions against the entity if such entity

3 knowingly and willfully charges for an item or service or

4 accepts payment in violation of subsection (a).

5 Subtitle C—Revenues

6 SEC. 421. FEDERAL SOURCES OF REVENUES.

7 (a) AMERICAN HEALTH SECURITY PLAN PRE8 MIUMS.—The Board, in consultation with the Secretary

9 of the Treasury, shall develop a mechanism for determin10 ing and collecting a premium from individuals and employ11 ers for health care services and long-term care services

12 covered under this Act, to be known as the American

13 Health Security Plan premium.

14 (b) DETERMINATION OF PREMIUM AMOUNT.—The

15 Board shall determine the American Health Security Plan

16 premium for each taxable year beginning after December

17 31, 1996, by estimating the total amount necessary to

18 equal the excess of—

19 (1) expenditures described in section 423(c) for

20 the fiscal year beginning in such taxable year, over

21 (2) receipts described in section 423(b) (other

22 than paragraph (1)) for such fiscal year.

23 (c) COLLECTION OF PREMIUM.—

24 (1) INDIVIDUALS.—The Board shall collect the

25 American Health Security Plan premium from indi-
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1 viduals using a mechanism with the following char2 acteristics:

3 (A) Income-based (including earned and

4 unearned income).

5 (B) Progressive.

6 (C) Payable in increments during the

7 course of the year.

8 (D) Payable by individuals or by employers

9 on behalf of employees (at the option of the em10 ployer), as described in paragraph (2)(C).

11 (E) Subject to the provisions of subtitle F

12 of the Internal Revenue Code of 1986.

13 (2) EMPLOYERS.—The Board shall collect the

14 American Health Security Plan premium from em15 ployers using a mechanism with the following char16 acteristics:

17 (A) Aggregate employer contributions

18 would equal an amount necessary to prevent an

19 increase in the percentage of 1993 aggregate

20 household health care expenditures.

21 (B) Contribution rate based on each em22 ployer’s ability to pay as indicated by factors

23 such as the size of the employer’s workforce

24 and profitability.
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1 (C) Any employer would have the option of

2 paying all or part of the American Health Secu3 rity Plan premium otherwise payable by such

4 employer’s employees.

5 (D) Subject to the provisions of subtitle F

6 of the Internal Revenue Code of 1986.

7 (d) EFFECT OF BOARD ACTIONS.—Any premium de8 termination made by the Board under this subsection with

9 respect to any taxable year shall be submitted to the Con10 gress at least 6 months before the beginning of such tax11 able year, and shall have the force of law, unless within

12 60 days of the submission of such determination, the Con13 gress enacts a disapproval resolution under the procedures

14 described in section 501.

15 (e) EFFECTIVE DATE.—The provisions of this section

16 shall apply with respect to remuneration paid after De17 cember 31, 1996, and with respect to earnings from self18 employment attributable to taxable years beginning after

19 such date.

20 SEC. 422. TAX TREATMENT OF AMERICAN HEALTH SECU21 RITY PLAN AND PRIVATE HEALTH AND LONG22 TERM CARE INSURANCE.

23 (a) TAX EXCLUSIONS FOR AMOUNTS RECEIVED

24 FROM, AND EMPLOYER CONTRIBUTIONS TO, THE

25 PLAN.—
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1 (1) AMOUNTS RECEIVED.—Subsection (e) of

2 section 105 of the Internal Revenue Code of 1986

3 (relating to amounts received under accident and

4 health plans) is amended to read as follows:

5 ‘‘(e) ACCIDENT OR HEALTH INSURANCE.—For pur6 poses of this section, section 104, and section 106, the

7 term ‘accident or health insurance’ means an approved

8 State program under section 311 of the American Health

9 Security Plan Act of 1993.’’.

10 (2) EMPLOYER CONTRIBUTIONS.—Section 106

11 of such Code (relating to contributions by employer

12 to accident and health plans) is amended by striking

13 ‘‘an accident or health plan’’ and inserting ‘‘accident

14 or health insurance’’.

15 (3) CONFORMING AMENDMENT.—Section 105

16 of such Code is amended by striking subsection (h).

17 (b) BUSINESS EXPENSE DEDUCTION FOR HEALTH

18 INSURANCE.—Section 162 of the Internal Revenue Code

19 of 1986 (relating to trade or business expenses) is amend20 ed by redesignating subsection (m) as subsection (n) and

21 by inserting after subsection (l) the following new sub22 section:

23 ‘‘(m) GROUP HEALTH PLANS.—The expenses paid or

24 incurred by an employer for a group health plan shall not

25 be allowed as a deduction under this section unless the
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1 plan is an approved State program under section 311 of

2 the American Health Security Plan Act of 1993.’’.

3 (c) RULES RELATING TO DEDUCTIONS FOR INDIVID4 UALS.—

5 (1) SAME TREATMENT FOR SELF-EMPLOYED

6 INDIVIDUALS AND BUSINESSES.—Section 162(l) of

7 the Internal Revenue Code of 1986 (relating to spe8 cial rules for health insurance costs of self-employed

9 individuals) is amended—

10 (A) by striking ‘‘25 percent of’’ in para11 graph (1), and

12 (B) by striking paragraph (6).

13 (2) SIMILAR TREATMENT FOR OTHER INDIVID14 UALS.—Subsection (d) of section 213 of such Code

15 (relating to medical, dental, etc., expenses) is

16 amended—

17 (A) by striking paragraph (1) and insert18 ing the following new paragraph:

19 ‘‘(1) MEDICAL CARE.—The term ‘medical care’

20 means American Health Security Plan premiums

21 and cost-sharing amounts paid for coverage under

22 an approved State program under section 311 of the

23 American Health Security Plan Act of 1993.’’,

24 (B) by striking paragraphs (2), (6), (7),

25 and (9), and by redesignating paragraphs (3),
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•HR 1691 IH

1 (4), (5), and (8) as paragraphs (2), (3), (4),

2 and (5), respectively.

3 (d) TERMINATION OF CHILD HEALTH INSURANCE

4 CREDIT.—Clause (i) of section 32(b)(2)(A) of such Code

5 is amended by inserting ‘‘(0 percent for taxable years be6 ginning after December 31, 1999)’’ after ‘‘6 percent’’.

7 (e) EFFECTIVE DATE.—The amendments made by

8 this section shall apply with respect to any taxable year

9 beginning after December 31, 1999.

10 SEC. 423. FEDERAL HEALTH TRUST FUND.

11 (a) TRUST FUND ESTABLISHED.—There is hereby

12 created on the books of the Treasury of the United States

13 a trust fund to be known as the ‘‘Federal Health Care

14 Trust Fund’’. The Trust Fund shall consist of such gifts

15 and bequests as may be made and such amounts as may

16 be deposited in, or appropriated to, such Trust Fund as

17 provided in this Act.

18 (b) RECEIPTS.—

19 (1) TRANSFER OF AMOUNTS EQUIVALENT TO

20 CERTAIN TAXES.—

21 (A) IN GENERAL.—There are hereby ap22 propriated to the Trust Fund amounts equiva23 lent to 100 percent of the American Health Se24 curity Plan premiums received in the Treasury
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1 as the result of the mechanism described in sec2 tion 421 of this Act.

3 (B) ADDITIONAL REVENUES.—There are

4 appropriated to the Trust Fund amounts equiv5 alent to the additional revenues received in the

6 Treasury as the result of the amendments made

7 by section 422 of this Act.

8 (C) TRANSFERS BASED ON ESTIMATES.—

9 The amounts appropriated by subparagraphs

10 (A) and (B) shall be transferred from time to

11 time (not less frequently than monthly) from

12 the general fund in the Treasury to the Trust

13 Fund, such amounts to be determined on the

14 basis of estimates by the Secretary of the

15 Treasury of the taxes and premiums, specified

16 in such subparagraphs, paid to or deposited

17 into the Treasury; and proper adjustments shall

18 be made in amounts subsequently transferred to

19 the extent prior estimates were in excess of or

20 were less than the taxes and premiums specified

21 in such subparagraphs.

22 (2) TRANSFER OF FUNDS.—All amounts, not

23 otherwise obligated, that remain in the Federal Hos24 pital Insurance Trust Fund and the Federal Supple25 mental Medical Insurance Trust Fund on the first
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1 day of the fiscal year 2000 shall be transferred to

2 the Trust Fund.

3 (3) APPROPRIATION OF ADDITIONAL SUMS.—

4 For fiscal years beginning after September 30,

5 1999, there are hereby authorized to be appro6 priated, and are appropriated, to the Trust Fund

7 such additional sums as equal the amounts appro8 priated with respect to title XIX of the Social Secu9 rity Act, section 1079 of title 10, United States

10 Code (CHAMPUS), and chapter 89 of title 5, Unit11 ed States Code, as in effect for fiscal year 1999.

12 Such amount shall be adjusted each fiscal year by

13 the increase in the Consumer Price Index (as deter14 mined by the Department of Labor) for the previous

15 fiscal year.

16 (4) APPROPRIATION OF SUMS FOR ADMINISTRA17 TIVE COSTS.—For fiscal years 1995, 1996, and

18 1997, there are hereby authorized to be appro19 priated, and are appropriated, to the Trust Fund

20 such additional sums as may be required to make

21 expenditures referred to in subsection (c)(2).

22 (5) RETURNED GRANT FUNDS.—Any returned

23 grant funds as described in section 316(a)(2) of this

24 Act shall be transferred to the Trust Fund.

25 (c) EXPENDITURES.—
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1 (1) TO STATES.—Payments in each fiscal year

2 to each State from the Trust Fund as determined

3 under section 402 are hereby authorized and appro4 priated.

5 (2) ADMINISTRATIVE EXPENSES AND

6 GRANTS.—There are hereby authorized and appro7 priated such sums as are necessary for the adminis8 trative expenses and grants described in sections

9 212(g), 304, 315, 316(c) and 803 of this Act for

10 each fiscal year.

11 (3) CONTINGENCY ACCOUNT.—There are here12 by authorized and appropriated such sums as deter13 mined necessary by the Board to cover unanticipated

14 events that affect the health care needs of individ15 uals described in section 101(a), to be available

16 without fiscal year limitation.

17 (d) INCORPORATION OF TRUST FUND PROVISIONS.—

18 The provisions of subsections (b) through (e) of section

19 1841 of the Social Security Act (42 U.S.C. 1395t), as in

20 effect on the day before the date of the enactment of this

21 Act, shall apply to the Trust Fund in the same manner

22 as such provisions apply to the Federal Supplemental

23 Medical Insurance Trust Fund, except that any reference

24 to the Secretary of Health and Human Services or the
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1 Administrator of the Health Care Financing Administra2 tion shall be deemed a reference to the Board.

3 (e) TRUST FUND OFF-BUDGET.—The receipts and

4 disbursements of the Trust Fund and the taxes described

5 in subsection (b)(1) shall not be included in the totals of

6 the budget of the United States Government as submitted

7 by the President or of the congressional budget and shall

8 be exempt from any general budget limitation imposed by

9 statute on expenditures and net lending (budget outlays)

10 of the United States Government.

11 SEC. 424. STATE SOURCES OF REVENUES.

12 (a) IN GENERAL.—Each State shall be responsible

13 for establishing a financing program for the implementa14 tion of the State program in the State. Such financing

15 program may include—

16 (1) funds used to finance the State share of

17 medicaid under title XIX of the Social Security Act

18 as in effect on the day before the date described in

19 section 902(f) of this Act,

20 (2) State and local funding for public hospitals

21 and other indigent care programs, and

22 (3) State funding from general revenues, ear23 marked taxes, payroll taxes, sales taxes, and such

24 other measures consistent with this Act as the State

25 may provide.
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1 (b) ON-GOING ENTITLEMENT.—Each State with a

2 State program approved by the Commission is entitled to

3 funding from the Commission in the amounts provided

4 under section 402.

5 TITLE V—CONGRESSIONAL

6 CONSIDERATION

7 SEC. 501. RULES GOVERNING CONGRESSIONAL CONSIDER8 ATION.

9 (a) RULES OF HOUSE OF REPRESENTATIVES AND

10 SENATE.—This section is enacted by the Congress—

11 (1) as an exercise of the rulemaking power of

12 the House of Representatives and the Senate, re13 spectively, and as such is deemed a part of the rules

14 of each House, respectively, but applicable only with

15 respect to the procedure to be followed in that

16 House in the case of disapproval resolutions de17 scribed in subsection (b), and supersedes other rules

18 only to the extent that such rules are inconsistent

19 therewith; and

20 (2) with full recognition of the constitutional

21 right of either House to change the rules (so far as

22 relating to the procedure of that House) at any time,

23 in the same manner and to the same extent as in

24 the case of any other rule of that House.
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1 (b) TERMS OF THE RESOLUTION.—For purposes of

2 this Act, the term ‘‘disapproval resolution’’ means only a

3 joint resolution of the two Houses of the Congress, provid4 ing in—

5 (1) the matter after the resolving clause of

6 which is as follows: ‘‘That the Congress disapproves

7 the action of the Federal Health Board as submitted

8 by the Board on llllllllllllll’’,

9 the blank space being filled in with the appropriate

10 date; and

11 (2) the title of which is as follows: ‘‘Joint Reso12 lution disapproving the action of the Federal Health

13 Board’’.

14 (c) INTRODUCTION AND REFERRAL.—On the day on

15 which the action of the Board is transmitted to the House

16 of Representatives and the Senate, a disapproval resolu17 tion with respect to such action shall be introduced (by

18 request) in the House of Representatives by the Majority

19 Leader of the House, for himself and the Minority Leader

20 of the House, or by Members of the House designated by

21 the Majority Leader of the House, for himself and the Mi22 nority Leader of the House, or by Members of the House

23 designated by the Majority Leader and Minority Leader

24 of the House; and shall be introduced (by request) in the

25 Senate by the Majority Leader of the Senate, for himself
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1 and the Minority Leader of the Senate, or by Members

2 of the Senate designated by the Majority Leader and Mi3 nority Leader of the Senate. If either House is not in ses4 sion on the day on which such an action is transmitted,

5 the disapproval resolution with respect to such action shall

6 be introduced in the House, as provided in the preceding

7 sentence, on the first day thereafter on which the House

8 is in session. The disapproval resolution introduced in the

9 House of Representatives and the Senate shall be referred

10 to the appropriate committees of each House.

11 (d) AMENDMENTS PROHIBITED.—No amendment to

12 a disapproval resolution shall be in order in either the

13 House of Representatives or the Senate; and no motion

14 to suspend the application of this subsection shall be in

15 order in either House, nor shall it be in order in either

16 House for the Presiding Officer to entertain a request to

17 suspend the application of this subsection by unanimous

18 consent.

19 (e) PERIOD FOR COMMITTEE AND FLOOR CONSIDER20 ATION.—

21 (1) IN GENERAL.—Except as provided in para22 graph (2), if the committee or committees of either

23 House to which a disapproval resolution has been re24 ferred have not reported it at the close of the 45th

25 day after its introduction, such committee or com-
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1 mittees shall be automatically discharged from fur2 ther consideration of the disapproval resolution and

3 it shall be placed on the appropriation calendar. A

4 vote on final passage of the disapproval resolution

5 shall be taken in each House on or before the close

6 of the 45th day after the disapproval resolution is

7 reported by the committees or committee of that

8 House to which it was referred, or after such com9 mittee or committees have been discharged from fur10 ther consideration of the disapproval resolution. If

11 prior to the passage by one House of a disapproval

12 resolution of that House, that House receives the

13 same disapproval resolution from the other House

14 then—

15 (A) the procedure in that House shall be

16 the same as if no disapproval resolution had

17 been received from the other House; but

18 (B) the vote on final passage shall be on

19 the disapproval resolution of the other House.

20 (2) COMPUTATION OF DAYS.—For purposes of

21 paragraph (1), in computing a number of days in ei22 ther House, there shall be excluded any day on

23 which the House is not in session.

24 (f) FLOOR CONSIDERATION IN THE HOUSE OF REP25 RESENTATIVES.—
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1 (1) MOTION TO PROCEED.—A motion in the

2 House of Representatives to proceed to the consider3 ation of a disapproval resolution shall be highly priv4 ileged and not debatable. An amendment to the mo5 tion shall not be in order, nor shall it be in order

6 to move to reconsider the vote by which the motion

7 is agreed to or disagreed to.

8 (2) DEBATE.—Debate in the House of Rep9 resentatives on a disapproval resolution shall be lim10 ited to not more than 20 hours, which shall be di11 vided equally between those favoring and those op12 posing the disapproval resolution. A motion further

13 to limit debate shall not be debatable. It shall not

14 be in order to move to recommit a disapproval reso15 lution or to move to reconsider the vote by which a

16 disapproval resolution is agreed to or disagreed to.

17 (3) MOTION TO POSTPONE.—Motions to post18 pone, made in the House of Representatives with re19 spect to the consideration of a disapproval resolu20 tion, and motions to proceed to the consideration of

21 other business, shall be decided without debate.

22 (4) APPEALS.—All appeals from the decisions

23 of the Chair relating to the application of the Rules

24 of the House of Representatives to the procedure re-
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1 lating to a disapproval resolution shall be decided

2 without debate.

3 (5) GENERAL RULES APPLY.—Except to the ex4 tent specifically provided in the preceding provisions

5 of this subsection, consideration of a disapproval res6 olution shall be governed by the Rules of the House

7 of Representatives applicable to other bills and reso8 lutions in similar circumstances.

9 (g) FLOOR CONSIDERATION IN THE SENATE.—

10 (1) MOTION TO PROCEED.—A motion in the

11 Senate to proceed to the consideration of a dis12 approval resolution shall be privileged and not debat13 able. An amendment to the motion shall not be in

14 order, nor shall it be in order to move to reconsider

15 the vote by which the motion is agreed to or dis16 agreed to.

17 (2) GENERAL DEBATE.—Debate in the Senate

18 on a disapproval resolution, and all debatable mo19 tions and appeals in connection therewith, shall be

20 limited to not more than 20 hours. The time shall

21 be equally divided between, and controlled by, the

22 Majority Leader and the Minority Leader or their

23 designees.

24 (3) DEBATE OF MOTIONS AND APPEALS.—De25 bate in the Senate on any debatable motion or ap-
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1 peal in connection with a disapproval resolution shall

2 be limited to not more than 1 hour, to be equally di3 vided between, and controlled by, the mover and the

4 manager of the disapproval resolution, except that in

5 the event the manager of the disapproval resolution

6 is in favor of any such motion or appeal, the time

7 in opposition thereto, shall be controlled by the Mi8 nority Leader or his designee. Such leaders, or ei9 ther of them, may, from time under their control on

10 the passage of a disapproval resolution, allot addi11 tional time to any Senator during the consideration

12 of any debatable motion or appeal.

13 (4) OTHER MOTIONS.—A motion in the Senate

14 to further limit debate is not debatable. A motion to

15 recommit a disapproval resolution is not in order.

16 (h) POINT OF ORDER REQUIRING SUPERMAJORITY

17 FOR MODIFICATIONS TO ACTIONS ONCE APPROVED.—

18 (1) IN GENERAL.—It shall not be in order in

19 the House of Representatives or the Senate to con20 sider any amendment to the actions of the Federal

21 Health Board except as provided in paragraph (2).

22 (2) WAIVER.—The point of order described in

23 paragraph (1) may be waived or suspended in the

24 House of Representatives or the Senate only, by the
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1 affirmative vote of three-fifths of the Members duly

2 chosen and sworn.

3 TITLE VI—PRIVATE OPTIONS

4 SEC. 601. PRIVATE SUPPLEMENTAL INSURANCE.

5 Except as provided in section 603, nothing in this Act

6 shall be construed to prohibit the purchase of private in7 surance that provides coverage of health care and long8 term care services supplementing the services covered

9 under this Act.

10 SEC. 602. OPTION TO PURCHASE DUPLICATIVE PRIVATE IN11 SURANCE.

12 Except as provided in section 603, nothing in this Act

13 shall be construed to prohibit the purchase of private in14 surance that provides coverage of health care and long15 term care services covered under this Act.

16 SEC. 603. LIMITS ON PRIVATE INSURANCE.

17 (a) IN GENERAL.—No insurer may issue a private

18 insurance policy if such policy provides coverage for the

19 cost-sharing requirements for health care services and

20 other non-long-term care services covered under this Act.

21 (b) CERTIFICATION OF NOTIFICATION.—At the time

22 of sale, the issuer of any private insurance policy shall se23 cure in writing a certification by the purchaser that the

24 purchaser has been informed of any duplication in cov25 erage of the services covered under this Act.
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1 (c) REVIEW OF PRACTICES.—No later than 2 years

2 after the full implementation of the provisions of this Act,

3 the Comptroller General of the United States shall review

4 the practices of the private insurance industry and make

5 such recommendations as necessary to the Congress in

6 order to prevent fraud and abuse in the sale of duplicative

7 or supplemental private health insurance and to protect

8 the integrity of the American Health Security Plan.

9 (d) OBLIGATION TO PAY PREMIUM REMAINS.—The

10 purchase of any type of private health insurance policy

11 shall not relieve the purchaser of the payment of the

12 American Health Security Plan premium imposed under

13 section 421.

14 TITLE VII—EXPANSION OF OUT15 COMES RESEARCH AND DE16 LIVERY OF SERVICES IN UN17 DERSERVED AREAS

18 SEC. 701. EXPANSION OF OUTCOMES RESEARCH.

19 Paragraph (1) of section 1142(i) of the Social Secu20 rity Act (42 U.S.C. 1320b–12(i)) is amended by striking

21 ‘‘and’’ at the end of subparagraph (D) and by striking

22 (E) and inserting the following:

23 ‘‘(E) $225,000,000 for fiscal year 1994;

24 ‘‘(F) $275,000,000 for fiscal year 1995;

25 and
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1 ‘‘(G) $325,000,000 for fiscal year 1996.’’.

2 SEC. 702. NATIONAL HEALTH SERVICE CORPS.

3 (a) INCREASE IN AUTHORIZATION OF APPROPRIA4 TIONS.—There are authorized to be appropriated to carry

5 out subpart II of part D of title III of the Public Health

6 Services Act (42 U.S.C. 254d et seq.) for fiscal year 1994,

7 an amount equal to—

8 (1) the amount appropriated under such sub9 part for fiscal year 1993; and

10 (2) an additional amount equal to 40 percent of

11 the amount described in paragraph (1).

12 When making loans under such subpart, priority should

13 be given to students from schools that have primary care

14 programs and that stress underserved practices.

15 (b) COMMUNITY FINANCING PROGRAM.—Subpart II

16 of part D of title III of the Public Health Service Act

17 (42 U.S.C. 254d et seq.) is amended by inserting after

18 section 336A, the following new section:

19 ‘‘SEC. 336B. COMMUNITY FINANCING PROGRAMS.

20 ‘‘(a) ESTABLISHMENT.—The Secretary may award

21 grants under this section to local communities to enable

22 such communities to establish programs to finance the

23 health-related education of residents of such communities.

24 ‘‘(b) APPLICATION.—To be eligible to receive a grant

25 under subsection (a), a community shall prepare and sub-
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1 mit to the Secretary an application, at such time, in such

2 manner and containing such information as the Secretary

3 may require.

4 ‘‘(c) USE.—A community that receives a grant under

5 subsection (a), shall use amounts received under such

6 grant to provide assistance to local residents with respect

7 to the health-related educational expenses of such resi8 dents. Such community shall not provide assistance under

9 a grant under this section to a local resident unless such

10 resident agrees to practice in a health-related field in such

11 community for not less than 4 years after graduation. In

12 providing assistance to such residents, the community

13 should give priority to residents attending schools that

14 have primary care programs and that stress underserved

15 practices.

16 ‘‘(d) AMOUNTS.—The amount of a grant awarded to

17 a community under this section shall not exceed 75 per18 cent of the cost to such community in administering and

19 implementing a community financing program under this

20 section.

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

22 are authorized to carry out this section, $10,000,000 for

23 each of the fiscal year 1994 through 1996.’’.
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1 SEC. 703. COMMUNITY AND MIGRANT HEALTH CENTERS.

2 Subpart I of part D of title III of the Public Health

3 Service Act (42 U.S.C. 254d et seq.) is amended by insert4 ing after section 330, the following new section:

5 ‘‘SEC. 330A. NEW COMMUNITY AND MIGRANT HEALTH CEN6 TERS.

7 ‘‘(a) NEW COMMUNITY AND MIGRANT HEALTH CEN8 TERS.—

9 ‘‘(1) IN GENERAL.—The Secretary shall award

10 grants to eligible entities to expand the availability

11 of comprehensive primary health services (as defined

12 in section 330(b)(1)) in medically underserved areas.

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

14 grant under this section an entity shall—

15 ‘‘(A) be an entity that—

16 ‘‘(i) meets the requirements of section

17 329(a) or 330(a) for being a migrant or

18 community health center, though not a re19 cipient of a grant under either section;

20 ‘‘(ii) does not meet the requirements

21 of section 329(a) or 330(a) for being a mi22 grant or community health center, but that

23 provides assurances satisfactory to the Sec24 retary, including subsequent demonstrable

25 evidence, that such entity will meet the re26 quirements of either section not later than
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1 2 years after receiving a grant under this

2 section;

3 ‘‘(iii) is eligible for a planning grant

4 under sections 329(c) or 330(c); or

5 ‘‘(iv) is able to provide a subset of the

6 required services, be able to prove that it

7 cannot meet the requirements of section

8 329(a) or 330(a), and demonstrate that it

9 is the most qualified entity in the service

10 area; and

11 ‘‘(B) prepare and submit to the Secretary

12 an application at such time, in such manner

13 and containing such information as the Sec14 retary may require.

15 ‘‘(b) EXPANSION OF CURRENT COMMUNITY AND MI16 GRANT HEALTH CENTERS.—

17 ‘‘(1) IN GENERAL.— Community and migrant

18 health centers in existence on the date of enactment

19 of this section may utilize any increase in revenue

20 experienced as a result of the increase in the number

21 of insured patients treated for the expansion of the

22 amounts and types of services furnished, to serve ad23 ditional patients or areas, or to promote the recruit24 ment, training or retention of personnel.
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1 ‘‘(2) RECOMMENDATIONS.—Not later than 3

2 years after the date of enactment of this section, the

3 Secretary shall prepare and submit to the appro4 priate committees of Congress recommendations con5 cerning the provision of paragraph (1).

6 ‘‘(c) REPORT.—Not later than 3 years after the date

7 of enactment of this section, the Secretary shall prepare

8 and submit to the appropriate committees of Congress a

9 report concerning the need for further migrant and com10 munity health center primary care service capacity devel11 opment and recommendations concerning the appropriate

12 level of support needed for activities to address such ca13 pacity development.

14 ‘‘(d) AUTHORIZATIONS OF APPROPRIATIONS.—

15 ‘‘(1) IN GENERAL.—There are authorized to be

16 appropriated to carry out this section, $300,000,000

17 for fiscal years 1994 through 1996.

18 ‘‘(2) ADDITIONAL AMOUNTS.—Amounts pro19 vided under this section shall be in addition to any

20 amounts appropriated under sections 329 and 330.’’.

21 TITLE VIII—MALPRACTICE

22 REFORM

23 SEC. 801. GRANTS TO STATES.

24 (a) IN GENERAL.—The Board shall make grants to

25 States for the development and implementation of medical
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1 malpractice reforms, as described in section 802. A State

2 shall use a grant made under this section to develop, im3 plement, and evaluate the effectiveness of such reforms.

4 (b) COMPLIANCE WITH FEDERAL STANDARDS.—Be5 ginning 2 years after the implementation of the reforms,

6 each State shall annually submit a report to the Board

7 containing such information as the Board may require to

8 determine whether the State is in compliance with the

9 terms of the grant made under this section.

10 SEC. 802. CRITERIA FOR STATE MALPRACTICE REFORMS.

11 (a) IN GENERAL.—Each State must demonstrate to

12 the Board that the reforms to the State medical mal13 practice system that the State develops or has already

14 adopted or intends to adopt meet the criteria described

15 in subsection (b).

16 (b) CRITERIA.—The criteria for medical malpractice

17 reforms are as follows:

18 (1) COSTS.—Decrease administrative costs and

19 reduce incentives for filing non-meritorious claims.

20 (2) EFFICIENCY.—Reduce the time between the

21 filing of medical malpractice claims and case resolu22 tions using procedures which may include the estab23 lishment of voluntary alternative dispute resolution

24 mechanisms, such as mediation, arbitration,
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1 minitrials, and summary judgments, to facilitate ear2 lier case resolutions.

3 (3) ACCESS.—Develop mechanisms to ensure

4 that victims of malpractice or medically injured pa5 tients have the meaningful ability to seek compensa6 tion, including voluntary alternative dispute resolu7 tion mechanisms designed for small claims.

8 (4) QUALITY.—Improve the quality of health

9 care by strengthening mechanisms that reduce the

10 occurrence of medical injury, and detect and sanc11 tion health care professionals who commit health

12 care malpractice.

13 (5) EQUITY.—Enhance the fairness of com14 pensation provided to injured individuals for both

15 medically and non-medically-related damages, and

16 increase incentives for experience rating of insurance

17 premiums.

18 (c) BOARD STUDY OF CRITERIA.—

19 (1) STUDY.—The Board shall collect data from

20 the States awarded grants under section 801 on the

21 effects of the reforms established to meet the criteria

22 described in subsection (b) on the medical mal23 practice systems of such States. The data shall be

24 used to evaluate the effectiveness and appropriate25 ness of the criteria described in subsection (b) in ad-
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1 dressing the problems of the medical malpractice

2 systems of such States. The Board may modify such

3 criteria based on such study.

4 (2) REPORT.—The Board shall report the re5 sults of the study described in paragraph (1) to the

6 Congress on a periodic basis.

7 SEC. 803. AUTHORIZATION OF APPROPRIATIONS.

8 There are authorized to be appropriated for grants

9 under this title such sums as may be necessary for fiscal

10 years 1994 through 1997.

11 TITLE IX—EFFECTIVE DATES;

12 TERMINATIONS; TRANSITION;

13 RELATION TO ERISA.

14 SEC. 901. EFFECTIVE DATES.

15 (a) FEDERAL ADMINISTRATION.—Not later than Oc16 tober 1, 1995, the Board shall promulgate regulations re17 garding the health care and long-term care services cov18 ered under this Act and the related patient cost-sharing

19 schedules under title II, develop the means for computing

20 the National Health Budget and Federal contributions to

21 the States under subtitle A of title IV, and establish the

22 procedures for reviewing and approving State plans under

23 section 311.

24 (b) PROVISION OF SERVICES.—
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1 (1) PREVENTIVE AND PRIMARY CARE SERV2 ICES.—The provision of preventive and primary care

3 services under approved State plans, as established

4 under section 201, shall take effect with respect to

5 services furnished on or after October 1, 1997.

6 (2) ACUTE CARE SERVICES.—The provision of

7 acute care services under approved State plans, as

8 established under section 201, shall take effect with

9 respect to services furnished on or after October 1,

10 1998.

11 (3) LONG-TERM CARE SERVICES.—The provi12 sion of long-term care services under approved State

13 plans, as established under section 202, shall take

14 effect with respect to services furnished on or after

15 October 1, 1999.

16 (c) MODIFICATION OF TRANSITION PERIOD.—

17 (1) IN GENERAL.—Notwithstanding any other

18 provision of this Act and to the extent the Board de19 termines it is appropriate and fiscally responsible,

20 the Board may promulgate regulations to reduce the

21 period between the date of the enactment of this Act

22 and the effective dates otherwise provided in this

23 Act.

24 (2) EFFECT OF BOARD ACTIONS.—Any deter25 mination made by the Board under this subsection
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1 to change an effective date under this Act shall be

2 submitted to the Congress at least 6 months before

3 the new effective date, and shall have the force of

4 law, unless within 60 days of the submission of such

5 determination, the Congress enacts a disapproval

6 resolution under the procedures described in section

7 501.

8 SEC. 902. TERMINATION OF OTHER PROGRAMS.

9 (a) MEDICARE AND MEDICAID.—

10 (1) IN GENERAL.—Titles XVIII and XIX of the

11 Social Security Act are repealed.

12 (2) REPEAL OF HOSPITAL INSURANCE TAXES

13 UPON FULL IMPLEMENTATION OF PLAN.—Sections

14 1401(b), 1402(k)(2), 3101(b), 3111(b), 3121(x)(2),

15 3231(e)(2)(B)(i)(II), and 6413(c)(3) of the Internal

16 Revenue Code of 1986 are repealed.

17 (b) REPEAL OF CHAMPUS PROVISIONS.—

18 (1) AMENDMENTS TO CHAPTER 55 OF TITLE

19 10.—Sections 1079 through 1083, 1086, and 1097

20 through 1100 of title 10, United States Code, are

21 repealed.

22 (2) TABLE OF SECTIONS.—The table of sections

23 at the beginning of chapter 55 of title 10, United

24 States Code, is amended by striking out the items

25 relating to the sections referred to in paragraph (1).
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1 (3) CONFORMING AMENDMENTS.—Chapter 55

2 of title 10, United States Code, is amended as fol3 lows:

4 (A) DEFINITION.—Section 1072 is amend5 ed by striking out paragraph (4).

6 (B) REIMBURSEMENT OF THE DEPART7 MENT OF VETERANS AFFAIRS.—Section

8 1104(b) is amended—

9 (i) in the subsection heading, by strik10 ing out ‘‘FROM CHAMPUS FUNDS’’; and

11 (ii) by striking out ‘‘from funds’’ and

12 all that follows and inserting in lieu thereof

13 ‘‘for medical care provided by the Depart14 ment of Veterans Affairs pursuant to such

15 agreement.’’.

16 (c) REPEAL OF FEDERAL EMPLOYEES HEALTH

17 BENEFITS PROGRAM.—Chapter 89 of title 5, United

18 States Code, is repealed.

19 (d) EFFECTIVE DATE.—The repeals and amend20 ments made by this section shall take effect on October

21 1, 1999.

22 SEC. 903. TRANSITION.

23 (a) IN GENERAL.—The Board shall issue such regu24 lations as are necessary to provide for a transition to the
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1 American Health Security Plan established under this Act

2 from the programs repealed under section 902.

3 (b) RELATION TO OTHER PROGRAMS.—The Board

4 shall recommend to the Congress appropriate legislative

5 proposals for the amendment or repeal of any other Fed6 eral program inconsistent with, or duplicative of, the prin7 ciples of the American Health Security Plan established

8 under this Act.

9 SEC. 904. RELATION TO ERISA.

10 The provisions of the Employee Retirement Income

11 Security Act are superseded to the extent inconsistent

12 with the requirements of this Act.

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