period that begins on the date the Secretary issues
the response. If the Secretary denies the State’s ap-
plication, the Secretary shall provide the State with
a written explanation of the grounds for the deci-
sion.
PART 2—UNIFORM STANDARDS FOR MEDICAL
MALPRACTICE LIABILITY ACTIONS
SEC. 141. STATUTE OF LIMITATIONS.
(a) IN GENERAL.—No medical malpractice liability
claim may be brought after the expiration of the 2-year
period that begins on the date the alleged injury that is
the subject of the action should reasonably have been dis-
covered, but in no event after the expiration of the 4-year
period that begins on the date the alleged injury occurred.
(b) EXCEPTION FOR MINORS.—In the case of an al-
leged injury suffered by a minor who has not attained 6
years of age, no medical malpractice liability claim may
be brought after the expiration of the 2-year period that
begins on the date the alleged injury that is the subject
of the action should reasonably have been discovered, but
in no event after the date on which the minor attains 10
years of age.
SEC. 142. REQUIREMENT FOR INITIAL RESOLUTION OF AC-
TION THROUGH ALTERNATIVE DISPUTE RES-
OLUTION.
(a) IN GENERAL.—No medical malpractice liability
action may be brought in any State court unless the medi-
cal malpractice liability claim that is the subject of the
action has been initially resolved under an alternative dis-
pute resolution system certified by the Secretary under
section 162(b).
(b) INITIAL
RESOLUTION
OF
CLAIMS
UNDER
ADR.—For purposes of subsection (a), an action is ‘‘ini-
tially resolved’’ under an alternative dispute resolution
system if—
(1) the ADR reaches a decision on whether the
defendant is liable to the plaintiff for damages; and
(2) if the ADR determines that the defendant
is liable, the ADR determines the amount of dam-
ages assessed against the defendant.
(c) PROCEDURES FOR FILING ACTIONS.—
(1) DEADLINE.—No medical malpractice liabil-
ity action may be brought unless the action is filed
in a court of competent jurisdiction not later than
90 days after an opinion resolving the medical mal-
practice liability claim that is the subject of the ac-
tion is issued under the applicable alternative dis-
pute resolution system.
(2) COURT
OF
COMPETENT
JURISDICTION.—
For purposes of paragraph (1), the term ‘‘court of
competent jurisdiction’’ means—
(A) with respect to actions filed in a State
court, the appropriate State trial court; and
(B) with respect to actions filed in a Fed-
eral court, the appropriate United States dis-
trict court.
(d) STATUS
OF
ADR DECISION.—The decision
reached under an alternative dispute resolution system
shall, for purposes of enforcement by a court of competent
jurisdiction, have the same status in the court as the ver-
dict of a medical malpractice liability action adjudicated
in a State or Federal trial court.
(e) TREATMENT OF ADR DECISION.—
(1) REQUIREMENTS FOR GOING FORWARD WITH
ACTION.—In order to bring a medical malpractice li-
ability action to contest the decision made under the
previous alternative dispute resolution system with
respect to a medical malpractice liability claim, the
party contesting the decision must—
(A) show that—
(i) the decision was procured by cor-
ruption, fraud, or undue means,
(ii) there was partiality or corruption
under the system,
(iii) there was other misconduct under
the system that materially prejudiced the
party’s rights, or
(iv) the decision was based on an
error of law; or
(B) present new evidence before the trier
of fact that was not available for presentation
under the ADR system.
(2) BURDEN OF PROOF.—In any medical mal-
practice liability action, the trier of fact shall uphold
the decision made under the previous alternative dis-
pute resolution system with respect to the claim that
is the subject of the action unless the party contest-
ing the decision proves by a preponderance of the
evidence that the decision was incorrect.
SEC. 143. RELATION TO ALTERNATIVE DISPUTE RESOLU-
TION OF FEDERAL AGENCIES.
(a) MANDATORY APPLICATION OF FEDERAL ADR IN
MALPRACTICE CLAIMS AGAINST UNITED STATES.—Sec-
tion 2672 of title 28, United States Code, is amended by
striking the period at the end of the first paragraph and
inserting the following: ‘‘, except that each Federal agency
shall use arbitration or such alternative means of dispute
resolution to settle any tort claim against the United
States consisting of a medical malpractice liability claim
(as defined in section 132(8) of the American Consumers
Health Care Reform Act of 1992).’’.
(b) TRANSMITTAL
OF
INFORMATION
OF
MAL-
PRACTICE CLAIMS RESOLVED UNDER FEDERAL ADR.—
Section 584 of title 5, United States Code, as added by
section 4(b) of the Administrative Dispute Resolution Act
(Public Law 101–552), is amended by adding at the end
the following new subsection:
‘‘(k) Each agency shall transmit on a regular basis
to the Administrator for Health Care Policy and Research
information on issues in controversy consisting of medical
malpractice liability claims (as defined in section 132(8)
of the American Consumers Health Care Reform Act of
1992) that are resolved under the agency’s dispute resolu-
tion proceeding under this subchapter, in a manner that
assures that the identity of the parties to such proceedings
shall not be revealed.’’.
SEC. 144. MANDATORY PRE-TRIAL SETTLEMENT CON-
FERENCE.
(a) IN GENERAL.—Before the beginning of the trial
phase of any medical malpractice liability action, the par-
ties shall attend a conference called by the court for pur-
poses of determining whether grounds exist upon which
the parties may negotiate a settlement for the action.
(b) REQUIRING PARTIES TO SUBMIT SETTLEMENT
OFFERS.—At the conference called pursuant to subsection
(a), each party to a medical malpractice liability action
shall present an offer of settlement for the action.
SEC. 145. CALCULATION AND PAYMENT OF DAMAGES.
(a) LIMITATION ON NONECONOMIC DAMAGES.—The
total amount of noneconomic damages that may be award-
ed to a plaintiff and the members of the plaintiff’s family
for losses resulting from the injury which is the subject
of a medical malpractice liability action may not exceed
$250,000, regardless of the number of parties against
whom the action is brought or the number of actions
brought with respect to the injury.
(b) TREATMENT OF PUNITIVE DAMAGES.—
(1) 
LIMITATION
ON
AMOUNT.—The 
total
amount of punitive damages that may be imposed
under a medical malpractice liability action may not
exceed twice the total of the damages awarded to the
plaintiff and the members of the plaintiff’s family.
(2) PAYMENTS TO STATE FOR MEDICAL QUAL-
ITY ASSURANCE ACTIVITIES.—
(A) IN GENERAL.—Any punitive damages
imposed under a medical malpractice liability
action shall be paid to the State in which the
action is brought.
(B) ACTIVITIES
DESCRIBED.—A State
shall use amount paid pursuant to subpara-
graph (A) to carry out activities to assure the
safety and quality of health care services pro-
vided in the State, including (but not limited
to)—
(i) licensing or certifying health care
professionals and health care providers in
the State;
(ii) operating alternative dispute reso-
lution systems;
(iii) carrying out public education pro-
grams relating to medical malpractice and
the availability of alternative dispute reso-
lution systems in the State; and
(iv) carrying out programs to reduce
malpractice-related costs for retired provid-
ers or other providers volunteering to pro-
vide services in medically underserved
areas.
(C) MAINTENANCE OF EFFORT.—A State
shall use any amounts paid pursuant to sub-
paragraph (A) to supplement and not to replace
amounts spent by the State for the activities
described in subparagraph (B).
(c) PERIODIC PAYMENTS FOR FUTURE LOSSES.—If
more than $100,000 in damages for expenses to be in-
curred in the future is awarded to the plaintiff in a medi-
cal malpractice liability action, the defendant shall provide
for payment for such damages on a periodic basis deter-
mined appropriate by the court (based upon projections
of when such expenses are likely to be incurred), unless
the court determines that it is not in the plaintiff’s best
interests to receive payments for such damages on such
a periodic basis.
(d) MANDATORY OFFSETS FOR DAMAGES PAID BY
A COLLATERAL SOURCE.—
(1) IN GENERAL.—The total amount of dam-
ages received by a plaintiff in a medical malpractice
liability action shall be reduced (in accordance with
paragraph (2)) by any other payment that has been
or will be made to the individual to compensate the
plaintiff for the injury that was the subject of the
action, including payment under—
(A) Federal or State disability or sickness
programs;
(B) Federal, State, or private health insur-
ance programs;
(C) private disability insurance programs;
(D) employer wage continuation programs;
and
(E) any other source of payment intended
to compensate the plaintiff for such injury.
(2) AMOUNT OF REDUCTION.—The amount by
which an award of damages to a plaintiff shall be re-
duced under paragraph (1) shall be—
(A) the total amount of any payments
(other than such award) that have been made
or that will be made to the plaintiff to com-
pensate the plaintiff for the injury that was the
subject of the action; minus
(B) the amount paid by the plaintiff (or by
the spouse, parent, or legal guardian of the
plaintiff) to secure the payments described in
subparagraph (A).
SEC. 146. TREATMENT OF ATTORNEY’S FEES AND OTHER
COSTS.
(a) LIMITATION
ON ATTORNEY’S FEES.—If the
plaintiff in a medical malpractice liability action has en-
tered into an agreement with the plaintiff’s attorney to
pay the attorney’s fees on a contingency basis, the attor-
ney’s fees for the action may not exceed—
(1) 25 percent of the first $150,000 of any
award or settlement paid to the plaintiff; or
(2) 15 percent of any additional amounts paid
to the plaintiff.
(b) AWARDING
ATTORNEY’S
FEES
AND
OTHER
COSTS TO WINNING PARTY.—
(1) IN GENERAL.—If the court in a medical
malpractice liability action upholds a ruling of the
alternative dispute resolution system with respect to
whether or not a health care professional or health
care provider committed malpractice or with respect
to the amount of damages awarded, the court shall
require the party that contested the ruling to pay to
the opposing party the costs incurred by the oppos-
ing party under the action, including attorney’s fees,
fees paid to expert witnesses, and other litigation ex-
penses (but not including court costs, filing fees, or
other expenses paid directly by the party to the
court, or any fees or costs associated with the reso-
lution of the claim that is the subject of the action
under the alternative dispute resolution system).
(2) PERMITTING COURT TO WAIVE OR MODIFY
IMPOSITION OF COSTS.—A court may issue a written
order waiving or modifying the application of para-
graph (1) to a party if the court finds that the appli-
cation of such paragraph to the party would con-
stitute an undue hardship, or if the medical mal-
practice liability action raised a novel issue of law.
The order shall specify the grounds for the court’s
decision to waive or modify the application of such
paragraph.
SEC. 147. JOINT AND SEVERAL LIABILITY.
The liability of each defendant in a medical mal-
practice liability action shall be several only and shall not
be joint, and each defendant shall be liable only for the
amount of damages allocated to the defendant in direct
proportion to the defendant’s percentage of responsibility
(as determined by the trier of fact).
SEC. 148. UNIFORM STANDARD FOR DETERMINING NEG-
LIGENCE.
A defendant in a medical malpractice liability action
may not be found to have acted negligently unless the de-
fendant’s conduct at the time of providing the health care
services that are the subject of the action was not reason-
able.
SEC. 149. APPLICATION OF MEDICAL PRACTICE GUIDE-
LINES IN MALPRACTICE LIABILITY ACTIONS.
(a) USE
OF GUIDELINES
AS AFFIRMATIVE DE-
FENSE.—In any medical malpractice liability action, it
shall be a complete defense to any allegation that the de-
fendant was negligent that, in the provision of (or the fail-
ure to provide) the services that are the subject of the
action, the defendant followed the appropriate practice
guideline.
(b) RESTRICTION ON GUIDELINES CONSIDERED AP-
PROPRIATE.—
(1) 
GUIDELINES
SANCTIONED
BY
SEC-
RETARY.—For purposes of subsection (a), a practice
guideline may not be considered appropriate with re-
spect to actions brought during a year unless the
Secretary has sanctioned the use of the guideline for
purposes of an affirmative defense to medical mal-
practice liability actions brought during the year in
accordance with paragraph (2) or (3).
(2) PROCESS FOR SANCTIONING GUIDELINES.—
Not less frequently than October 1 of each year (be-
ginning with 1993), the Secretary, shall review the
practice guidelines and standards developed by the
Administrator for Health Care Policy and Research
pursuant to section 1142 of the Social Security Act,
and shall sanction those guidelines which the Sec-
retary considers appropriate for purposes of an af-
firmative defense to medical malpractice liability ac-
tions brought during the next calendar year as ap-
propriate practice guidelines for purposes of sub-
section (a).
(3) USE OF STATE GUIDELINES.—Upon the ap-
plication of a State, the Secretary may sanction
practice guidelines selected by the State for purposes
of an affirmative defense to medical malpractice li-
ability actions brought in the State as appropriate
practice guidelines for purposes of subsection (a) if
the guidelines meet such requirements as the Sec-
retary may impose.
(c) PROHIBITING APPLICATION OF FAILURE TO FOL-
LOW GUIDELINES AS PRIMA FACIE EVIDENCE OF NEG-
LIGENCE.—No plaintiff in a medical malpractice liability
action may be deemed to have presented prima facie evi-
dence that a defendant was negligent solely by showing
that the defendant failed to follow the appropriate practice
guideline.
SEC. 150. SPECIAL PROVISION FOR CERTAIN OBSTETRIC
SERVICES.
(a) IMPOSITION OF HIGHER STANDARD OF PROOF.—
(1) IN
GENERAL.—In the case of a medical
malpractice liability action relating to services pro-
vided during labor or the delivery of a baby, if the
defendant health care professional did not previously
treat the plaintiff for the pregnancy, the trier of fact
may not find that the defendant committed mal-
practice and may not assess damages against the de-
fendant unless the malpractice is proven by clear
and convincing evidence.
(2) APPLICABILITY TO GROUP PRACTICES OR
AGREEMENTS AMONG PROVIDERS.—For purposes of
paragraph (1), a health care professional shall be
considered to have previously treated an individual
for a pregnancy if the professional is a member of
a group practice whose members previously treated
the individual for the pregnancy or is providing serv-
ices to the individual during labor or the delivery of
a baby pursuant to an agreement with another pro-
fessional.
(b) CLEAR AND CONVINCING EVIDENCE DEFINED.—
In subsection (a), the term ‘‘clear and convincing evi-
dence’’ is that measure or degree of proof that will
produce in the mind of the trier of fact a firm belief or
conviction as to the truth of the allegations sought to be
established, except that such measure or degree of proof
is more than that required under preponderance of the evi-
dence, but less than that required for proof beyond a rea-
sonable doubt.
(c) EFFECTIVE DATE.—This section shall apply to
claims accruing or actions brought on or after the expira-
tion of the 2-year period that begins on the date of the
enactment of this Act.
SEC. 151. PREEMPTION.
(a) IN GENERAL.—This part supersedes any State
law only to the extent that State law—
(1) permits the recovery of a greater amount of
damages by a plaintiff;
(2) permits the collection of a greater amount
of attorneys’ fees by a plaintiff’s attorney;
(3) establishes a longer period during which a
medical malpractice liability claim may be initiated;
or
(4) establishes a stricter standard for determin-
ing whether a defendant was negligent or for deter-
mining the liability of defendants described in sec-
tion 150(a) in actions described in such section.
(b) EFFECT ON SOVEREIGN IMMUNITY AND CHOICE
OF LAW OR VENUE.—Nothing in subsection (a) shall be
construed to—
(1) waive or affect any defense of sovereign im-
munity asserted by any State under any provision of
law;
(2) waive or affect any defense of sovereign im-
munity asserted by the United States;
(3) affect the applicability of any provision of
the Foreign Sovereign Immunities Act of 1976;
(4) preempt State choice-of-law rules with re-
spect to claims brought by a foreign nation or a citi-
zen of a foreign nation; or
(5) affect the right of any court to transfer
venue or to apply the law of a foreign nation or to
dismiss a claim of a foreign nation or of a citizen
of a foreign nation on the ground of inconvenient
forum.
PART 3—REQUIREMENTS FOR STATE ALTERNATIVE
DISPUTE RESOLUTION SYSTEMS (ADR)
SEC. 161. BASIC REQUIREMENTS FOR ADR.
(a) IN GENERAL.—A State’s alternative dispute reso-
lution system meets the requirements of this section if the
system—
(1) applies to all medical malpractice liability
claims under the jurisdiction of the State courts;
(2) requires that a written opinion resolving the
dispute be issued that contains findings of fact relat-
ing to the dispute;
(3) requires individuals who hear and resolve
claims under the system to meet such qualifications
as the State may require (in accordance with regula-
tions of the Secretary);
(4) is approved by the State or by local govern-
ments in the State;
(5) with respect to a State system that consists
of multiple dispute resolution procedures—
(A) permits the parties to a dispute to se-
lect the procedure to be used for the resolution
of the dispute under the system, and
(B) if the parties do not agree on the pro-
cedure to be used for the resolution of the dis-
pute, assigns a particular procedure to the par-
ties;
(6) provides for the transmittal to the State
agency responsible for monitoring or disciplining
health care professionals and health care providers
of any findings made under the system that such a
professional or provider committed malpractice, un-
less, during the 90-day period beginning on the date
the system resolves the claim against the profes-
sional or provider, the professional or provider
brings a medical malpractice liability action contest-
ing the decision made under the system; and
(7) provides for the regular transmittal to the
Administrator for Health Care Policy and Research
of information on disputes resolved under the sys-
tem, in a manner that assures that the identity of
the parties to a dispute shall not be revealed.
(b) APPLICATION
OF
MALPRACTICE
LIABILITY
STANDARDS TO ALTERNATIVE DISPUTE RESOLUTION.—
The provisions of part 2 shall apply with respect to claims
brought under a State’s alternative dispute resolution sys-
tem in the same manner as such provisions apply with
respect to medical malpractice liability actions brought in
the State.
SEC. 162. CERTIFICATION OF STATE SYSTEMS.
(a) IN GENERAL.—Not later than October 1 of each
year (beginning with 1993), the Secretary, in consultation
with the Attorney General, shall determine whether a
State’s alternative dispute resolution system meets the re-
quirements of this part for the following calendar year.
(b) BASIS FOR CERTIFICATION.—The Secretary shall
certify a State’s alternative dispute resolution system
under this subsection if the Secretary determines under
subsection (a) that the system meets the requirements of
section 161.
SEC. 163. REPORTS ON IMPLEMENTATION AND EFFECTIVE-
NESS OF ALTERNATIVE DISPUTE RESOLU-
TION SYSTEMS.
(a) IN GENERAL.—Not later than 5 years after the
date of the enactment of this Act, the Secretary shall pre-
pare and submit to Congress a report describing and eval-
uating State alternative dispute resolution systems oper-
ated pursuant to this part.
(b) CONTENTS OF REPORT.—The Secretary shall in-
clude in the report prepared and submitted under sub-
section (a)—
(1) information on—
(A) the effect of such systems on the cost
of health care within the State,
(B) the impact of such systems on the ac-
cess of individuals to health care within the
State, and
(C) the effect of such systems on the qual-
ity of health care provided within such State;
and
(2) to the extent that such report does not pro-
vide information on no-fault systems operated by
States as alternative dispute resolution systems pur-
suant to this part, an analysis of the feasibility and
desirability of establishing a system under which
medical malpractice liability claims shall be resolved
on a no-fault basis.
PART 4—OTHER REQUIREMENTS AND PROGRAMS
SEC. 171. FACILITATING DEVELOPMENT AND USE OF
MEDICAL PRACTICE GUIDELINES.
(a) INCREASE IN AUTHORIZATION OF APPROPRIA-
TIONS.—Section 1142(i)(1) of the Social Security Act (42
U.S.C. 1320b–12(i)(1)) is amended by striking subpara-
graphs (D) and (E) and inserting the following:
‘‘(D) $158,000,000 for fiscal year 1993 (of
which $10,000,000 shall be used for sanction-
ing practice guidelines for purposes of an af-
firmative defense in medical malpractice liabil-
ity actions);
‘‘(E) $200,000,000 for fiscal year 1994 (of
which $20,000,000 shall be used for sanction-
ing practice guidelines for purposes of an af-
firmative defense in medical malpractice liabil-
ity actions); and
‘‘(F) $20,000,000 for fiscal year 1995, to
be used for sanctioning practice guidelines for
purposes of an affirmative defense in medical
malpractice liability actions.’’.
(b) CONSIDERATION
OF MALPRACTICE LIABILITY
DATA IN DEVELOPING AND UPDATING GUIDELINES.—
Section 1142(c)(5) of such Act (42 U.S.C. 1320b–
12(c)(5)) is amended by striking ‘‘claims data’’ and all
that follows through ‘‘patients’’ and inserting the follow-
ing: ‘‘claims data, data on clinical and functional status
of patients, and data on medical malpractice liability ac-
tions’’.
(c) DEVELOPMENT
OF
REPORTING
FORMS
FOR
STATE ADR SYSTEMS.—The Secretary, in consultation
with the Administrator for Health Care Policy and Re-
search, shall develop a standard reporting form to be used
by State alternative dispute resolution systems in trans-
mitting information to the Administrator pursuant to sec-
tion 161(a)(6) on disputes resolved under such systems.
(d) STUDY OF EFFECT OF GUIDELINES ON MEDICAL
MALPRACTICE.—
(1) STUDY.—The Secretary shall conduct a
study of the effect of the use of the medical practice
guidelines developed by the Administrator for Health
Care Policy and Research on the incidence of and
the costs associated with medical malpractice.
(2) REPORTS.—(A) Not later than 1 year after
the date of the enactment of this Act, the Secretary
shall submit an interim report to Congress describ-
ing the availability and use of medical practice
guidelines and the aggregate costs associated with
medical malpractice.
(B) Not later than 5 years after the date of the
enactment of this Act, the Secretary shall submit a
report to Congress on the study conducted under
paragraph (1), together with recommendations re-
garding expanding the use of medical practice guide-
lines for determining the liability of health care pro-
fessionals and health care providers for medical mal-
practice.
SEC. 172. PERMITTING STATE PROFESSIONAL SOCIETIES
TO PARTICIPATE IN DISCIPLINARY ACTIVI-
TIES.
(a) ROLE OF PROFESSIONAL SOCIETIES.—Notwith-
standing any other provision of State or Federal law, a
State agency responsible for the conduct of disciplinary
actions for a type of health care practitioner may enter
into agreements with State or county professional societies
of such type of health care practitioner to permit such so-
cieties to participate in the licensing of such health care
practitioner, and to review any health care malpractice ac-
tion, health care malpractice claim or allegation, or other
information concerning the practice patterns of any such
health care practitioner. Any such agreement shall comply
with subsection (b).
(b) REQUIREMENTS OF AGREEMENTS.—Any agree-
ment entered into under subsection (a) for licensing activi-
ties or the review of any health care malpractice action,
health care malpractice claim or allegation, or other infor-
mation concerning the practice patterns of a health care
practitioner shall provide that—
(1) the health care professional society conducts
such activities or review as expeditiously as possible;
(2) after the completion of such review, such so-
ciety shall report its findings to the State agency
with which it entered into such agreement;
(3) the conduct of such activities or review and
the reporting of such findings be conducted in a
manner which assures the preservation of confiden-
tiality of health care information and of the review
process; and
(4) no individual affiliated with such society is
liable for any damages or injury directly caused by
the individual’s actions in conducting such activities
or review.
(c) AGREEMENTS NOT MANDATORY.—Nothing in
this section may be construed to require a State to enter
into agreements with societies described in subsection (a)
to conduct the activities described in such subsection.
(d) EFFECTIVE DATE.—This section shall take effect
2 years after the date of the enactment of this Act.
SEC. 173. REQUIREMENTS FOR RISK MANAGEMENT PRO-
GRAMS.
(a) REQUIREMENTS FOR PROVIDERS.—Each State
shall require each health care professional and health care
provider providing services in the State to participate in
a risk management program to prevent and provide early
warning of practices which may result in injuries to pa-
tients or which otherwise may endanger patient safety.
(b) REQUIREMENTS
FOR INSURERS.—Each State
shall require each entity which provides health care profes-
sional or provider liability insurance to health care profes-
sionals and health care providers in the State to—
(1) establish risk management programs based
on data available to such entity or sanction pro-
grams of risk management for health care profes-
sionals and health care providers provided by other
entities; and
(2) require each such professional or provider,
as a condition of maintaining insurance, to partici-
pate in one program described in paragraph (1) at
least once in each 3-year period.
(c) EFFECTIVE DATE.—This section shall take effect
2 years after the date of the enactment of this Act.
SEC. 174. GRANTS FOR MEDICAL SAFETY PROMOTION.
(a) RESEARCH ON MEDICAL INJURY PREVENTION
AND COMPENSATION.
nonprofit organizations, and health professional
schools (as defined in paragraph (3)) for—
(A) educating the general public about the
appropriate use of health care and realistic ex-
pectations of medical intervention;
(B) educating the public about the re-
sources and role of health care professional li-
censing and disciplinary boards in investigating
claims of incompetence or health care mal-
practice; and
(C) developing programs of faculty train-
ing and curricula for educating health care pro-
fessionals in quality assurance, risk manage-
ment, and medical injury prevention.
(2) APPLICATIONS.—The Secretary may not
make a grant under paragraph (1) unless the appli-
cant submits an application to the Secretary at such
time, in such form, in such manner, and containing
such information as the Secretary shall require.
(3) 
HEALTH
PROFESSIONAL
SCHOOL
DE-
FINED.—In paragraph (1), the term ‘‘health profes-
sional school’’ means a school of nursing (as defined
in section 853(2) of the Public Health Service Act)
or a school or program described in section 799(1)
of such Act.
(d) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated not more than
$15,000,000 for each of the first 5 fiscal years beginning
on or after the date of the enactment of this Act for grants
under this section.
SEC. 175. STUDY OF BARRIERS TO VOLUNTARY SERVICE BY
PHYSICIANS.
(a) STUDY.—The Secretary shall conduct a study to
determine the factors preventing or discouraging physi-
cians (whether practicing or retired) from volunteering to
provide health care services in medically underserved
areas.
(b) REPORTS.—(1) Not later than 1 year after the
date of the enactment of this Act, the Secretary shall sub-
mit an interim report to Congress on the study conducted
under subsection (a), together with the Secretary’s rec-
ommendations for actions to increase the number of physi-
cians volunteering to provide health care services in medi-
cally underserved areas.
(2) Not later than 5 years after the date of the enact-
ment of this Act, the Secretary shall submit a final report
to Congress on the study conducted under subsection (a)
(taking into account the effects of this subtitle on the inci-
dence and costs of medical malpractice), together with the
Secretary’s recommendations for actions to increase the
number of physicians volunteering to provide health care
services in medically underserved areas.
Subtitle E—Medical Education
Reform
SEC. 181. LIMITATION ON MEDICARE HOSPITAL PAYMENT
FOR DIRECT AND INDIRECT GRADUATE MED-
ICAL EDUCATION SUPPORT AND FEDERAL
ASSISTANCE FOR INSURED MEDICAL STU-
DENT LOANS FOR NON-PRIMARY CARE PHY-
SICIANS.
(a) MEDICARE DIRECT GRADUATE MEDICAL EDU-
CATION FUNDING.—Section 1886(h) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)) is amended—
(1) in paragraph (1), by inserting ‘‘subject to
paragraph (6),’’ after ‘‘1861(v),’’, and
(2) by adding at the end the following new
paragraph:
‘‘(6) TRANSITION TO EQUAL ASSISTANCE FOR
PRIMARY CARE.—
‘‘(A) PLAN.—The Secretary shall develop a
plan for adjusting payments made under this
section in a manner that—
‘‘(i) results, for each fiscal year begin-
ning more than 10 years after the date of
the enactment of this paragraph, in aggre-
gate expenditures under this subsection for
approved medical residency training pro-
grams in primary care fields equal to 50
percent of the aggregate expenditures
under this subsection for all training pro-
grams, and
‘‘(ii) does not result in expenditures
under this section exceeding the expendi-
tures that would otherwise have been made
under this subsection without regard to
this paragraph.
Within 1 year after the date of the enactment
of this paragraph, the Secretary shall submit a
report to Congress on the plan developed under
this subparagraph.
‘‘(B) IMPLEMENTATION.—Unless the Con-
gress otherwise provides by law, the Secretary
is authorized to implement the plan developed
under subparagraph (A).’’.
(b) MEDICARE
INDIRECT
MEDICAL
EDUCATION
FUNDING.—Section 1886(d)(5)(B) of such Act is amend-
ed by adding at the end the following new clause:
‘‘(v) Notwithstanding the previous provisions of
this subparagraph, the Secretary shall develop a
plan for adjusting additional payments made under
this subparagraph in a manner that—
‘‘(I) results, for each fiscal year beginning
more than 10 years after the date of the enact-
ment of this clause, in aggregate expenditures
under this subparagraph for indirect costs of
medical education of physicians in primary care
fields equal to 50 percent of the aggregate addi-
tional payments under this subparagraph, and
‘‘(II) does not result in additional pay-
ments under this subparagraph exceeding the
payments that would otherwise have been made
under this subparagraph without regard to this
clause.
Within 1 year after the date of the enactment of this
clause, the Secretary shall submit a report to Con-
gress on the plan developed under this clause. Un-
less the Congress otherwise provides by law, the Sec-
retary is authorized to implement the plan developed
under this clause.’’.
(c) INSURED STUDENT LOANS.—Section 702 of the
Public Health Service Act is amended by adding at the
end the following new subsection:
‘‘(d)(1) The Secretary shall develop and implement
a plan for the insuring of loans under this subpart in a
manner that results in aggregate new loans made for each
fiscal year beginning more than 10 years after the date
of the enactment of this subsection and for installments
with respect to such loans pursuant to lines of credit under
this subpart for students at schools of medicine for stu-
dents in primary care fields equal to 50 percent of the
aggregate of such loans and installments for students in
any medical field at such schools of medicine.
‘‘(2) Within 1 year after the date of the enactment
of this subsection, the Secretary shall submit a report to
Congress on the plan developed under paragraph (1). Un-
less the Congress otherwise provides by law, the Secretary
is authorized to implement the plan developed under para-
graph (1).’’.
SEC. 182. STATE COMPREHENSIVE HEALTH PROFESSIONS
EDUCATION PLANS.
Each State shall develop a comprehensive plan to
identify the health personnel needs of the residents of the
State, addressing shortages of and specialty requirements
for health care providers.
Subtitle F—Public Delivery System
SEC. 183. IDENTIFICATION OF MEDICALLY UNDERSERVED
POPULATIONS.
The Secretary of Health and Human Services,
through the Public Health Service, shall develop national
standards to identify medically underserved populations
and the areas in which such populations are.
SEC. 184. STATE COMPREHENSIVE PLANS FOR MEDICALLY
UNDERSERVED POPULATIONS.
(a) IN GENERAL.—Each State shall develop a com-
prehensive plan for addressing the health care needs of
populations identified, under the standards established
under section 183, as medically underserved.
(b) USE OF RESOURCES.—Each such plan shall uti-
lize, in the most efficient manner possible, the current re-
sources of Federal, State, and local governments, includ-
ing local public health clinics.
SEC. 185. PUBLICLY-FUNDED HEALTH CENTERS SERVING
MEDICALLY UNDERSERVED AREAS.
(a) OBJECTIVE.—It is the policy of the Congress to
provide for at least one publicly-funded health center in
each area identified, under section 186, as serving medi-
cally underserved populations.
(b) ADDITIONAL AUTHORIZATION
OF APPROPRIA-
TIONS.—In addition to the amounts otherwise authorized,
there are authorized to be appropriated such additional
amounts to provide for such additional grants under sec-
tions 329, 330, and 340 of the Public Health Service Act
(relating to migrant health, community health centers,
and grant programs for certain health services for the
homeless) as may be required to carry out the policy stat-
ed in subsection (a).
SEC. 186. OFFICE OF DISEASE PREVENTION AND HEALTH
PROMOTION.
(a) IN GENERAL.—Section 1701(a)(11) of the Public
Health Service Act (42 U.S.C. 300u(a)(11)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (C),
(2) by redesignating subparagraph (D) as sub-
paragraph (E), and
(3) by inserting after subparagraph (C) the fol-
lowing new subparagraph:
‘‘(D) promote individual responsibility in
personal health care and in the use of valuable
health care resources; and’’.
(b) FUNDING.—It is the sense of the Congress that
the amounts that are appropriated pursuant to section
1701(b) of the Public Health Service Act should be in-
creased for fiscal year 1993 and each fiscal year thereafter
in a manner sufficient to permit the Office of Disease Pre-
vention and Health Promotion to carry out—
(1) its duties under section 1701(a)(1)(D) of
such Act (as amended by subsection (a)), and
(2) the activities for which additional funding
was requested in the President’s request for appro-
priations for the Office for fiscal year 1993, includ-
ing implementation the initiatives to ‘‘Put Preven-
tion into Practice’’, for ‘‘Healthy Schools’’, and for
‘‘Health Communication Technology’’.
SEC. 187. CONSOLIDATION OF FEDERAL ACTIVITIES RELAT-
ING TO NUTRITION.
(a) IN GENERAL.—The President shall provide for
the coordination and, to the extent appropriate, consolida-
tion of all Federal activities and programs relating to nu-
trition.
(b) PURPOSES.—The coordination and consolidation
required by subsection (a) shall—
(1) eliminate confusing and contradictory Fed-
eral policies with respect to nutritional issues,
(2) place greater emphasis on the relevance of
nutrition to disease prevention and health pro-
motion, and
(3) promote public education on the effects of
nutrition on personal health.
SEC. 188. DEMONSTRATION PROJECTS ON HEALTH CARE
DECISIONMAKING.
(a) IN GENERAL.—Not later than one year after the
date of the enactment of this Act, the Secretary of Health
and Human Services shall establish under section
1701(a)(11) of the Public Health Service Act at least 4
demonstration projects to test alternative ways of promot-
ing informed decisionmaking by providers and patients on
the appropriate utilization of expensive life-sustaining
technology.
(b) PRIORITIES.—The demonstration projects under
subsection (a) shall include at least the following dem-
onstrations projects:
(1) A demonstration project, based on the
‘‘Health Decisions U.S.A.’’ demonstration, to edu-
cate the public about the implications of utilizing
new medical technologies and to measure the effects
of such education on individual behavior.
(2) A demonstration project to improve the va-
lidity and reliability of computerized data systems
designed to permit patients and their families to as-
sess the likely outcomes of using particular medical
technologies.
(3) A demonstration project to test the efficacy
of educating individuals in various settings, includ-
ing—
(A) the home,
(B) a physician’s office, and
(C) upon admission to a health care facil-
ity,
about their rights under State law to make decisions
regarding their medical treatment.
(4) A demonstration project that provides for
participation by experts on medical ethics in the de-
velopment of clinical practice guidelines.
(c) REPORTS
AND EVALUATIONS.—The Secretary
shall submit to Congress—
(1) an annual report on the status of each dem-
onstration project conducted under this section, and
(2) a final report to the Congress on each such
project not later than one year after the close of the
project.
The reports required by paragraph (2) shall be accom-
panied by such recommendations for legislation as the
Secretary determines to be appropriate to promote in-
formed decisionmaking by physicians and patients on the
utilization of medical technologies.
(d) FUNDING.—There are authorized to be appro-
priated such sums as may be necessary to carry out this
section.
SEC. 189. ACTION PLAN ON HEALTH PROMOTION AND DIS-
EASE PREVENTION.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall develop an action plan for reducing
the incidence in the United States of the following health
100
risk factors which have been identified in the publication
Healthy People, 2000:
(1) Smoking.
(2) High blood pressure.
(3) High blood cholesterol.
(4) Overweight.
(5) Sedentary lifestyle.
(6) High fat diet.
(7) Inadequate childhood immunization.
(8) Heavy use of alcohol.
(9) Failure to use seat belts.
(b) REVIEW OF FEDERAL POLICIES.—In developing
the action plan under subsection (a), the Secretary shall
identify current Federal policies that may hinder attain-
ment of the goals of the plan and shall consult with the
agencies responsible for the implementation of these poli-
cies.
(c) REPORTS.—The Secretary shall—
(1) transmit the action plan required by sub-
section (a) to the Congress not later than one year
after the date of the enactment of this Act, and
(2) submit to the Congress at least every 2
years thereafter a report that—
101
(A) describes progress made toward reduc-
ing the incidence of the health risk factors spec-
ified in such subsection, and
(B) includes recommendations for such
regulatory and legislative changes and other ac-
tions that should be taken to reduce further the
incidence of these health risk factors.
Subtitle G—Public Disclosure
SEC. 191. DEVELOPMENT OF NATIONAL STANDARDS FOR
DISCLOSURE OF HEALTH CARE INFORMA-
TION; IMPLEMENTATION BY STATES.
(a) NATIONAL STANDARDS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall establish standards for the
collection and disclosure of health care data pursu-
ant to this subtitle.
(2) ELEMENTS OF STANDARDS.—In establish-
ing such standards, the Secretary shall develop—
(A) a computerized system for use in the
collection, analysis, and disclosure of data col-
lected pursuant to this subtitle;
(B) a uniform claims format for use by all
data sources and providers in billing for health
care services for which data are required to be
submitted pursuant to this subtitle;
102
(C) a mechanism—
(i) to avoid duplicative reporting of
data for health care services furnished
under titles XVIII and XIX of the Social
Security Act, and
(ii) to coordinate and integrate the
data collected for such services with the
data collected for other health care serv-
ices; and
(D) a methodology for use in measuring
the quality and effectiveness of health care serv-
ices furnished by providers.
(b) STATE IMPLEMENTATION.—
(1) APPLICATION.—Any State desiring to per-
form the data collection and disclosure functions
specified in this subtitle for data sources and provid-
ers in the State may submit an application to the
Secretary. Such application shall be in a form and
manner specified by the Secretary.
(2) APPROVAL AND FINANCIAL ASSISTANCE.—If
the Secretary determines that the State has dem-
onstrated in its application that it has the ability to
carry out such functions and to comply with the
standards and other requirements of this subtitle—
103
(A) the Secretary shall approve such appli-
cation,
(B) the State shall become responsible for
the performance of the data collection and dis-
closure functions specified in this subtitle for
data sources and providers in the State, and
(C) the Secretary shall provide the State
with financial assistance in such amount as is
reasonably sufficient to carry out such functions
in the State.
(3) IMPLEMENTATION IN CASE OF NO QUALIFY-
ING STATE.—If, with respect to a State, an applica-
tion has not been approved under paragraph (2), the
Secretary shall become responsible for the perform-
ance of the data collection and disclosure functions
specified in this subtitle for data sources and provid-
ers in the State.
(4) RESPONSIBLE GOVERNMENTAL ENTITY DE-
FINED.—In this subtitle, the term ‘‘responsible gov-
ernmental entity’’ means for data sources and pro-
viders in a State—
(A) the State, if it has been granted such
responsibility under paragraph (2), or
(B) the Secretary, if the State has not
been granted such responsibility.
104
(c) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated such sums as may be
necessary to carry out this subtitle (including providing
financial assistance to qualifying States under subsection
(b)(2)).
SEC. 192. DATA SUBMISSION AND COLLECTION.
(a) SUBMISSION OF DATA.—The responsible govern-
mental entity shall collect, and data sources shall submit
to such entity, all data required in this section, according
to uniform submission formats, coding systems and other
technical specifications necessary to render the incoming
data substantially valid, consistent, compatible and man-
ageable using electronic data processing according to data
submission schedules, such schedules to avoid, to the ex-
tent possible, submission of identical data from more than
one data source, established and promulgated by the Sec-
retary pursuant to section 191(a)(2).
(b) UNIFORM CLAIMS FORMAT.—The Secretary shall
adopt, within 180 days of the date of the enactment of
this Act, a uniform claims format. The Secretary shall fur-
nish such format to all data sources and the form shall
be utilized and maintained by all data sources for all serv-
ices covered under this subtitle. Such form shall have such
fields as may be necessary to provide all of the data set
forth in subsections (c) and (d).
105
(c) DATA ELEMENTS.—For each covered service, the
responsible governmental entity shall collect the following
data elements:
(1) Uniform patient identifier, continuous
across multiple episodes and providers.
(2) Patient date of birth.
(3) Patient sex.
(4) Patient ZIP Code number.
(5) Date of admission.
(6) Date of discharge.
(7) Principal and up to four secondary diag-
noses by standard code.
(8) Principal procedure by standard code and
date.
(9) Up to three secondary procedures by stand-
ard codes and dates.
(10) Uniform health care facility identifier, con-
tinuous across episodes, patients, and providers.
(11) Uniform identifier of admitting physician,
by unique physician identification number estab-
lished by the Secretary, continuous across episodes,
patients, and providers.
(12) Uniform identifier of consulting physi-
cians, by unique physician identification number es-
106
tablished by the Secretary, continuous across epi-
sodes, patients, and providers.
(13) Total charges of health care facility, seg-
regated into major categories, including room and
board, radiology, laboratory, operating room, drugs,
medical supplies and other goods and services ac-
cording to guidelines specified by the Secretary.
(14) Actual payments to health care facility,
segregated, if available, according to the categories
specified in paragraph (13).
(15) Charges of each physician or professional
rendering service relating to an incident of hos-
pitalization or treatment in an ambulatory service
facility.
(16) actual payments to each physician or pro-
fessional rendering service pursuant to paragraph
(15).
(17) Uniform identifier of primary payor.
(18) ZIP Code number of facility where health
care service is rendered.
(19) Uniform identifier for payor group con-
tract number.
(20) Patient discharge status.
107
(21) Provider service effectiveness and provider
quality pursuant to section 191(a)(2)(D) and sub-
section (d).
(d) PROVIDER QUALITY AND PROVIDER SERVICE EF-
FECTIVENESS DATA ELEMENTS.—In carrying out its duty
to collect data on provider quality and provider service ef-
fectiveness under subsection (c)(21), the responsible gov-
ernmental entity shall utilize the methodology developed
under section 191(a)(2)(D).
(e) RESERVE FIELD UTILIZATION AND ADDITION OR
DELETION OF DATA ELEMENTS.—The Secretary shall in-
clude in the uniform claims format a reserve field. The
Secretary may utilize the reserve field by adding other
data elements beyond those specified in subsection (d) or
the Secretary may delete data elements from the format
pursuant to regulation after obtaining a cost-benefit anal-
ysis of the proposed addition or deletion which shall in-
clude the cost to data sources of any proposed additions.
(f) OTHER DATA REQUIRED TO BE SUBMITTED.—
Providers are hereby required to submit and the respon-
sible governmental entity shall collect the following addi-
tional data, if such data is not available to the entity from
public records:
108
(1) Audited annual financial reports of all hos-
pitals and ambulatory service facilities providing cov-
ered services.
(2) Additional data including data which can be
used to provide at least the following information:
(A) The incidence of medical and surgical
procedures in the population for individual pro-
viders.
(B) Physicians who provide covered serv-
ices and accept medical assistance patients.
(C) Physicians who provide covered serv-
ices and accept medicare assignment as full
payment.
(D) Status of licensure and accreditation
of hospitals and ambulatory service facilities.
(E) Mortality rates for specified diagnoses
and treatments, grouped by severity, for indi-
vidual providers.
(F) Rates of infection for specified diag-
noses and treatments, grouped by severity, for
individual providers.
(G) Morbidity rates for specified diagnoses
and treatments, grouped by severity, for indi-
vidual providers.
109
(H) Readmission rates for specified diag-
noses and treatments, grouped by severity, for
individual providers.
(I) Rate of incidence of postdischarge pro-
fessional care for selected diagnoses and treat-
ments, grouped by severity, for individual pro-
viders.
(g) ALLOWANCE
FOR
CLARIFICATION
OR
DIS-
SENTS.—The responsible governmental entity shall main-
tain a file of written statements submitted by data sources
who wish to provide an explanation of data that they feel
might be misleading or misinterpreted. The entity shall
provide access to such file to any person and shall, where
practical, in the entity’s reports and data files indicate the
availability of such statements. When the entity agrees
with such statements, the entity shall correct the appro-
priate data and comments in its data files and subsequent
reports.
(h) AVAILABILITY OF DATA.—Nothing in this sub-
title shall prohibit a purchaser from obtaining from its
health care insurer, nor relieve such a health care insurer
from the obligation of providing such purchaser, on terms
consistent with past practices, data previously provided or
additional data not currently provided to such provider by
110
such insurer pursuant to any existing or future arrange-
ment, agreement, or understanding.
SEC. 193. DATA DISSEMINATION AND PUBLICATION.
(a) PUBLIC REPORTS.—Subject to the restrictions on
access to data in section 194 and utilizing the data col-
lected under section 192 as well as other data, records,
and matters of record available to it, the responsible gov-
ernmental entity shall prepare and issue public reports ac-
cording to the following provisions:
(1) The responsible governmental entity shall,
for every provider and within appropriate geographic
areas (approved by the Secretary) and for those in-
patient and outpatient services which, when ranked
by order of frequency, account for at least 65 per-
cent of all covered services and which, when ranked
by order of total payments account for at least 65
percent of total payments, prepare and issue quar-
terly reports that at least provide information on the
following:
(A) Comparisons among all providers of
payments received, charges, population-based
admission or incidence rates, and provider serv-
ice effectiveness, such comparisons to be
grouped according to diagnosis and severity,
111
and to identify each provider by name and type
or specialty.
(B) Comparisons among all providers, ex-
cept physicians, of inpatient and outpatient
charges and payments for room and board, an-
cillary services, drugs, equipment and supplies
and total services, such comparisons to be
grouped according to provider quality and pro-
vider service effectiveness and according to di-
agnosis and severity, and to identify each health
care facility by name and type.
(C) Until the methodology to measure pro-
vider quality and provider service effectiveness
is developed under section 191(a)(2)(D), com-
parisons among all providers, grouped accord-
ing to diagnosis, procedure, and severity, which
identify facilities by name and type and physi-
cians by name and specialty, of charges and
payment received, readmission rates, mortality
rates, morbidity rates, and infection rates.
(D) The incidence rate of selected medical
or surgical procedures, the provider service ef-
fectiveness and the payments received for other
providers, identified by the name and type of
112
specialty, for which these elements vary signifi-
cantly from the norms for all providers.
(2) In preparing reports under paragraph (1),
the responsible governmental entity shall ensure that
factors which have the effect of either reducing pro-
vider revenue or increasing provider costs, and other
factors beyond a provider’s control which reduce the
provider competitiveness in the market place, are ex-
plained in the reports. The entity shall also ensure
that any clarifications and dissents submitted by in-
dividual providers under section 192(g) are noted in
any reports that include release of data on that indi-
vidual provider.
(3) The responsible governmental entity shall,
for all providers and within appropriate geographic
areas approved under paragraph (1), prepare and
issue quarterly reports that at least provide informa-
tion on the following:
(A) The number of physicians, by spe-
cialty, on the staff of each hospital or ambula-
tory service facility and those physicians on the
staff that accept medicare assignment as full
payment and that accept medical assistance pa-
tients.
113
(B) The status of hospitals respecting ac-
creditation and licensure.
If such entity is not the Secretary, the entity shall
transmit a copy of each report under this paragraph
to the Secretary.
(4) The responsible governmental entity shall
publish all reports issued under paragraph (3) in the
same periodical publication in which regulations of
the governmental entity are published and shall pub-
lish, in at least one newspaper of general circulation
in each approved geographic area, reports on the
providers in that area and areas adjacent to it. In
addition, the responsible governmental entity shall
advertise the availability of these reports and the
charge for duplication in such periodical publication
and in at least one newspaper of general circulation
in each such approved geographic area at least once
in each calendar quarter.
(b) RAW DATA REPORTS AND CONSUMER ACCESS TO
DATA.—The responsible governmental entity shall provide
special reports derived from raw data and a means for
computer-to-computer access to raw data to any pur-
chaser, pursuant to section 194(f). The responsible gov-
ernmental entity shall provide such reports and computer-
to-computer access, at the entity’s discretion, to other par-
114
ties, pursuant to section 194(g). The entity shall provide
these special reports and computer-to-computer access in
as timely a fashion as the entity’s responsibilities to pub-
lish the public reports required in this section will allow.
Any such provision of special reports or computer-to-com-
puter access by the council shall be made only subject to
the restrictions on access to raw data set forth in section
194(b) and only after payment for costs of preparation
or duplication pursuant to section 194 (f) or (g).
SEC. 194. ACCESS TO DATA.
(a) PUBLIC ACCESS.—The information and data re-
ceived by a responsible governmental entity under this
subtitle shall be utilized by the entity for the benefit of
the public. Subject to the specific limitations set forth in
this section, the entity shall make determinations on re-
quests for information in favor of access.
(b) LIMITATIONS
ON ACCESS.—Unless specifically
provided in this subtitle, the responsible governmental en-
tity shall not release—
(1) any raw data that does not simultaneously
disclose payment, as well as provider quality and
provider service effectiveness information;
(2) any raw data of the entity which could rea-
sonably be expected to reveal the identity of an indi-
vidual patient;
115
(3) any raw data which could reasonably be ex-
pected to reveal the identity of any purchaser, other
than a purchaser requesting data on its own group
or an entity entitled to such purchaser’s data pursu-
ant to subsection (f);
(4) any raw data relating to actual payments to
any identified provider made by any purchaser, ex-
cept that this paragraph shall not apply to access by
a purchaser requesting data on the group for which
it purchases or otherwise provides covered services
or to access to that same data by an entity entitled
to the purchaser’s data pursuant to subsection (f);
and
(5) any raw data disclosing discounts or dif-
ferentials between payments accepted by providers
for services and their billed charges obtained by
identified payors from identified providers unless
comparable data on all other payors is also released
and the entity determines that the release of such
information is not prejudicial or inequitable to any
individual payor or provider or group thereof.
In making determinations under paragraph (5), the entity
shall consider that the purpose of this subtitle is primarily
concerned with the analysis and dissemination of pay-
ments to providers, not with discounts.
116
(c) UNAUTHORIZED USE OF DATA.—Any person who
knowingly releases data violating the patient confidential-
ity, actual payments, discount data or raw data safeguards
set forth in this section to an unauthorized person is sub-
ject to imprisonment of not more than 5 years, or fine
according to title 18, United States Code.
(d) UNAUTHORIZED ACCESS TO DATA.—Should any
person inadvertently or by error of a responsible govern-
mental entity gain access to data that violates the safe-
guards set forth in this section, the data must immediately
be returned, without duplication, to the entity with proper
notification.
(e) PUBLIC ACCESS TO RECORDS.—All public records
prepared by the entity shall be available to the public for
a reasonable fee, not to exceed the cost of duplication.
(f) ACCESS TO RAW DATA BY PURCHASERS.—Sub-
ject to the limitations on access set forth in subsection
(b), the responsible governmental entity shall provide ac-
cess to its raw data to purchasers in accordance with the
following procedure:
(1) Special reports derived from raw data of the
entity shall be provided by the entity to any pur-
chaser requiring such reports.
(2) A means to enable computer-to-computer
access by any purchaser to raw data shall be devel-
117
oped, adopted, and implemented by the entity, and
the entity shall provide such access to raw data to
any purchaser upon request.
(3) In the event that any employer obtains from
the entity, pursuant to paragraph (1) or (2), data
pertaining to the employer’s employees and their de-
pendents for whom the employer purchases or other-
wise provides covered services and who are rep-
resented by a certified collective bargaining rep-
resentative, such collective bargaining representative
shall be entitled to that same data, after payment of
fees as specified in paragraph (4). Likewise, should
a certified collective bargaining representative obtain
from the entity, pursuant to paragraph (1) or (2),
data pertaining to members of the collective bargain-
ing unit and their dependents who are employed by
and for whom covered services are purchased or oth-
erwise provided by any employer, the employer shall
be entitled to that same data, after payment of fees
as specified in paragraph (4).
(4) In providing for access to raw data, the re-
sponsible governmental entity shall charge the pur-
chasers which originally obtained such access a fee
sufficient to cover the costs to prepare and provide
special reports requested pursuant to paragraph (1)
118
or to provide computer-to-computer access to its raw
data requested pursuant to paragraph (2). Should a
second or subsequent party or parties request this
same information pursuant to paragraph (3), the en-
tity shall charge such party a fee sufficient to cover
only the costs of duplicating the original access.
(g) ACCESS TO RAW DATA BY OTHER PARTIES.—
Subject to the limitations on access to raw data set forth
in subsection (b), the responsible governmental entity may
provide special reports derived from raw data or computer-
to-computer access to parties other than purchasers. The
entity shall publish regulations that set forth the criteria
and the procedure the entity shall use in making deter-
minations on such access. In providing such access, the
entity shall charge the party requesting the access a fee
sufficient to cover the entity’s costs of providing such ac-
cess.
SEC. 195. DEFINITIONS.
In this subtitle:
(1) The term ‘‘ambulatory service facility’’
means a licensed facility, not part of a hospital,
which provides medical, diagnostic, or surgical treat-
ment to patients not requiring hospitalization, in-
cluding ambulatory surgical facilities, ambulatory
imaging or diagnostic centers, birthing centers, free-
119
standing emergency rooms, and any other facilities
providing ambulatory care which charge a separate
facility charge. Such term does not include the of-
fices of private physicians or dentists, whether for
individual or group practices.
(2) The terms ‘‘charge’’ and ‘‘rate’’ means
amounts billed by a provider for specific goods or
services provided to a patient, prior to any adjust-
ment for contractual allowances.
(3) The term ‘‘covered services’’ means any
health care services or procedures connected with
episodes of illness that require either inpatient hos-
pital care or major ambulatory service such as sur-
gical, medical, or major radiological procedures, in-
cluding any initial and followup outpatient services
associated with the episode of illness before, during,
or after inpatient hospital care or major ambulatory
service. The term does not include routine outpatient
services connected with episodes of illness that do
not require hospitalization or major ambulatory serv-
ice.
(4) The term ‘‘data source’’ means a hospital,
ambulatory service facility, physician, health mainte-
nance organization, hospital or medical service plan,
commercial insurer, self-insured employer providing
120
health or accident coverage, administrator of a self-
insured or partially self-insured health or accident
plan providing covered services, any health and wel-
fare fund that provides health or accident benefits or
insurance pertaining to covered services, and any
other payor for covered services in the United States
other than an individual.
(5) The term ‘‘health care facility’’ means a
general or special hospital, including tuberculosis
and psychiatric hospitals, kidney disease treatment
centers, including freestanding hemodialysis units,
and ambulatory service facilities, and hospices (both
profit and nonprofit).
(6) The term ‘‘health maintenance organiza-
tion’’ means an organized system which combines
the delivery and financing of health care and which
provides basic health care services to voluntarily en-
rolled subscribers for a fixed prepaid fee.
(7) The term ‘‘hospital’’ means any institution
licensed in a State as a hospital, including hospitals
for tuberculosis, mental disease or chronic illness.
(8) The term ‘‘major ambulatory service’’
means surgical or medical procedures, including di-
agnostic and therapeutic radiological procedures,
commonly performed in hospitals or ambulatory
123
(17) The terms ‘‘raw data’’ and ‘‘data’’ mean
data collected by a responsible governmental entity
under section 192 in the form initially received.
(18) The term ‘‘responsible governmental en-
tity’’ has the meaning given such term in section
191(b)(4).
(19) The term ‘‘severity’’ means, in any patient,
the measurable degree of the potential for failure of
one or more vital organs.
(20) The term ‘‘Secretary’’ means the Secretary
of Health and Human Services.
(21) The term ‘‘State’’ means the 50 States
and the District of Columbia.
Subtitle H—Tax Incentives to
Provide Only Minimum Benefits
SEC. 198. DENIAL OF EMPLOYER TAX DEDUCTION FOR PRO-
VIDING HEALTH CARE COVERAGE IN EXCESS
OF MINIMUM BENEFITS AND DENIAL OF EM-
PLOYEE EXCLUSION FOR SUCH EXCESS COV-
ERAGE.
(a) DENIAL OF DEDUCTION.—Section 162 of the In-
ternal Revenue Code of 1986 (relating to trade or business
expenses) is amended by redesignating subsection (m) as
subsection (n) and by inserting after subsection (l) the fol-
lowing new subsection:
124
‘‘(m) EXPENSES FOR PROVIDING HEALTH CARE IN
EXCESS OF MINIMUM BENEFITS.—No deduction shall be
allowed under this chapter for expenses incurred to pro-
vide health care for any employee of the taxpayer (or any
beneficiary of such employee) to the extent such expenses
are attributable to benefits that are not within the mini-
mum benefit package which has become effective under
section 203(a)(2) of the American Consumers Health Care
Reform Act of 1993.’’
(b) DENIAL OF EXCLUSION.—The text of section 106
of such Code is amended to read as follows:
‘‘(a) IN GENERAL.—Gross income of an employee
does not include employer-provided coverage under an ac-
cident or health plan.
‘‘(b) NO EXCLUSION FOR HEALTH CARE COVERAGE
IN EXCESS OF MINIMUM BENEFITS.—Subsection (a) shall
not apply to the extent coverage is provided for benefits
that are not within the minimum benefit package which
has become effective under section 203(a)(2) of the Amer-
ican Consumers Health Care Reform Act of 1993.’’
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to taxable years beginning on or
after the first day of the second calendar year beginning
after the date of the enactment of this Act, but shall not
apply to taxable years beginning before the date the mini-
125
mum benefit package has become effective under section
203(a)(2) of this Act.
SEC. 199. DEDUCTION FOR HEALTH INSURANCE COSTS OF
SELF-EMPLOYED INDIVIDUALS MADE PERMA-
NENT AND INCREASED TO EXTENT OF COSTS
FOR MINIMUM BENEFITS.
(a) DEDUCTION MADE PERMANENT.—
(1) IN GENERAL.—Subsection (l) of section 162
of the Internal Revenue Code of 1986 (relating to
special rules for health insurance costs of self-em-
ployed individuals) is amended by striking paragraph
(6).
(2) TECHNICAL AMENDMENT.—Paragraph (2)
of section 110(a) of the Tax Extension Act of 1991
is hereby repealed.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to taxable years begin-
ning after December 31, 1991.
(b) INCREASE IN DEDUCTION FOR MINIMUM BENE-
FITS.—
(1) IN GENERAL.—Subsection (l) of section 162
of such Code is amended by adding at the end there-
of the following new paragraph:
‘‘(6) FULL DEDUCTION FOR COSTS OF MINIMUM
BENEFIT PACKAGE.—Paragraph (1) shall be applied
126
without regard to ‘25 percent of’ with respect to
costs attributable to benefits that are within the
minimum benefit package which has become effec-
tive under section 203(a)(2) of the American Con-
sumers Health Care Reform Act of 1993.’’
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to taxable years begin-
ning on or after the first day of the second calendar
year beginning after the date of the enactment of
this Act, but shall not apply to taxable years begin-
ning before the date the minimum benefit package
has become effective under section 203(a)(2) of this
Act.
TITLE II—NATIONAL HEALTH
CARE REFORM PROPOSALS
Subtitle A—National Health Care
Reform Commission
SEC. 201. ESTABLISHMENT.
(a) ESTABLISHMENT.—There is established an inde-
pendent commission to be known as the National Health
Care Reform Commission (in this title referred to as the
‘‘Commission’’).
(b) DUTIES.—The Commission shall carry out the
duties specified for it in this subtitle.
(c) APPOINTMENT.—
127
(1) COMPOSITION.—
(A) SIZE
AND
MANNER
OF
APPOINT-
MENT.—The Commission shall consist of—
(i) five members to be appointed by
the President, by and with the advice and
consent of the Senate, one of whom shall,
at the time of appointment, be designated
as Chairperson of the Commission;
(ii) two members to be appointed by
the Speaker of the House of Representa-
tives upon the recommendations of the Ma-
jority Leader and Minority Leader of the
House of Representatives; and
(iii) two members to be appointed by
the President pro tempore of the Senate
upon the recommendations of the Majority
Leader and Minority Leader of the Senate.
(B) POLITICAL AFFILIATION.—At no time
shall more than three of the members appointed
by the President, one of the members appointed
by the Speaker of the House of Representatives,
or one of the members appointed by the Presi-
dent pro tempore of the Senate be members of
the same political party.
128
(C) MEMBERSHIP
QUALIFICATIONS.—The
membership of the Commission shall consist of
individuals who are of recognized standing and
distinction and who possess the demonstrated
capacity to discharge the duties imposed on the
Commission, and shall include persons possess-
ing substantial knowledge or expertise in health
care delivery, health care insurance, or health
care economics. No individual who is otherwise
an officer or full-time employee of the United
States shall serve as a member of the Commis-
sion. No member while serving on the Commis-
sion may receive financial gain from direct in-
vestments, employment or associations from
any entity with demonstrable financial interest
in matters over which the Commission has ju-
risdiction.
(D) CHAIRPERSON.—The Chairperson of
the Commission shall designate a member of
the Commission to act as Vice Chairperson of
the Commission.
(E) QUORUM.—A majority of the members
of the Commission shall constitute a quorum,
but a lesser number may conduct hearings.
129
(F) TERM.—Members of the Commission
shall be appointed for a term of 5 years, except
that with respect to the members first ap-
pointed—
(i) the Chairperson and 2 members, 1
each appointed under clauses (ii) and (iii)
of paragraph (1)(A), respectively, shall be
appointed for a term of 5 years;
(ii) 3 members, 1 each appointed
under clauses (i), (ii) and (iii) of para-
graph (1)(A), respectively, shall be ap-
pointed for a term of 4 years; and
(iii) the remaining members shall be
appointed for a term of 3 years.
(G) VACANCY.—A vacancy in the Commis-
sion shall not affect its powers, but shall be
filled in the same manner as the original ap-
pointment, but the individual appointed shall
serve only for the unexpired portion of the term
for which the individual’s predecessor was ap-
pointed.
(2) EFFECTIVE
DATE.—Appointments to the
Commission shall be made no later than 90 days
after the date of enactment of this Act.
130
(d) MEETINGS.—The Commission shall meet at the
call of the Chairperson, or at the call of a majority of the
members of the Commission; but meetings shall not be
held less frequently than once in each calendar month
which begins after a majority of the membership of the
Commission has been appointed.
(e) HEARINGS.—In carrying out its duties under this
section, the Commission, or any duly authorized commit-
tee thereof, is authorized to hold such hearings, sit and
act at such times and places, and take such testimony,
with respect to matters with respect to which it has a re-
sponsibility under this title, as the Commission or such
committee may deem advisable. The Chairperson of the
Commission or any member authorized by the Chairperson
may administer oaths or affirmations to witnesses appear-
ing before the Commission or before any committee there-
of.
(f) PAY AND TRAVEL EXPENSES.—
(1) PAY.—
(A) MEMBERS.—Each member, other than
the Chairperson, shall be paid at a rate equal
to the daily equivalent of the minimum annual
rate of basic pay payable for level IV of the Ex-
ecutive Schedule under section 5315 of title 5,
United States Code, for each day (including
131
travel time) during which the member is en-
gaged in the actual performance of duties vest-
ed in the Commission.
(B) 
CHAIRPERSON.—The 
Chairperson
shall be paid for each day referred to in sub-
paragraph (A) at a rate equal to the daily
equivalent of the minimum annual rate of basic
pay payable for level III of the Executive
Schedule under section 5314 of title 5, United
States Code.
(2) TRAVEL EXPENSES.—Members shall receive
travel expenses, including per diem in lieu of subsist-
ence, in accordance with sections 5702 and 5703 of
title 5, United States Code.
(g) STAFF.—
(1) APPOINTMENT.—The Commission may em-
ploy and fix the compensation of an Executive Direc-
tor and such other personnel (not to exceed 25) as
may be necessary to carry out the duties of the
Commission. The employment and compensation of
such Director and personnel are not subject to the
provisions of title 5, United States Code, governing
appointments in the competitive service.
(2) DETAIL
OF
PERSONNEL
FROM
FEDERAL
AGENCIES.—Upon request of the Commission, the
132
head of any Federal department or agency may de-
tail any of the personnel of that department or agen-
cy to the Commission to assist the Commission in
carrying out its duties under this title.
(3) 
FEDERAL
AGENCY
ASSISTANCE.—The
Comptroller General of the United States, the Sec-
retary of Health and Human Services, and the Ad-
ministrator of General Services shall provide assist-
ance on a reimbursable basis, including the detailing
of employees, to the Commission in accordance with
an agreement entered into with the Commission.
(h) OTHER AUTHORITY.—
(1) CONSULTANT SERVICES.—The Commission
may procure by contract, to the extent funds are
available, the temporary or intermittent services of
experts or consultants pursuant to section 3109 of
title 5, United States Code.
(2) PROPERTY
MATTERS.—The Commission
may lease space and acquire personal property to the
extent funds are available.
(i) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated such sums as may be
necessary to carry out the purposes of this section.
133
SEC. 202. ESTABLISHMENT OF NATIONAL GOALS; CON-
SULTATIONS; 
IMPROVED 
COORDINATION;
EVALUATION AND RECOMMENDATIONS ON
DEMONSTRATION PROJECTS.
(a) IN GENERAL.—The Commission shall develop na-
tional health care goals in order to—
(1) improve access to necessary health care
services;
(2) safeguard and improve the quality of health
care services; and
(3) control the cost of health care services.
(b) CONSULTATIONS.—In carrying out the respon-
sibilities assigned to it under this Act, the Commission
shall seek out and consider recommendations from a broad
range of interested individuals and organizations, includ-
ing organizations representing health care consumers,
health care providers, health care carriers, representatives
of State health programs, public health professionals, and
the general public.
(c) IMPROVEMENT
IN COORDINATION.—The Com-
mission shall examine steps that can be taken to better
coordinate the activities of the Secretary of Health and
Human Services and other Departments and agencies in
promotion of the national health care goals developed
under subsection (a) in order to meet the goals stated in
the report ‘‘Healthy People, 2000’’.
134
(d) EVALUATION
AND RECOMMENDATIONS CON-
CERNING DEMONSTRATION PROJECTS.—The Commission
shall—
(1) advise the Secretary on the demonstration
projects established under subtitle B,
(2) assist the Secretary in the evaluation of
such projects, and
(3) make recommendations regarding changes
that should be made in laws or regulations as a re-
sult of such evaluations.
SEC. 203. ESTABLISHMENT OF MINIMUM BENEFIT PACK-
AGE.
(a) PROPOSAL.—
(1) SUBMISSION.—Not later than 1 year after
the date of the enactment of this Act, the Commis-
sion shall develop and submit to Congress a legisla-
tive proposal that specifies a minimum benefit pack-
age consistent with this section to be used for pur-
poses of—
(A) the demonstration project established
under section 211(c)(1),
(B) implementing subtitle C of title I, and
(C) determining the tax treatment under
the Internal Revenue Code of 1986 (as amend-
ed by section 198) of amounts paid by an em-
135
ployer on behalf of an employee for health in-
surance benefits in excess of the minimum ben-
efit package.
(2) IMPLEMENTATION.—The minimum benefit
package submitted under this paragraph (1) shall
not become effective for the purposes specified in
subparagraphs (B) and (C) of such paragraph un-
less a joint resolution approving such package is en-
acted in accordance with the procedures set forth in
subsection (d).
(b) BENEFITS.—The services included in the benefit
package shall include—
(1) coverage for preventive, diagnostic, and
therapeutic services found to be medically appro-
priate and cost effective, and
(2) cost-sharing that provides an appropriate
incentive to avoid unnecessary care while avoiding
excessive cost-sharing by individuals with cata-
strophic illnesses.
(c) CONGRESSIONAL CONSIDERATION
OF COMMIS-
SION PROPOSAL.—
(1) RULES
OF
HOUSE
OF
REPRESENTATIVES
AND
SENATE.—This subsection is enacted by the
Congress—
136
(A) as an exercise of the rulemaking power
of the House of Representatives and the Sen-
ate, respectively, and as such is deemed a part
of the rules of each House, respectively, but ap-
plicable only with respect to the procedure to be
followed in that House in the case of approval
resolutions described in paragraph (2), and su-
persedes other rules only to the extent that
such rules are inconsistent therewith; and
(B) with full recognition of the constitu-
tional right of either House to change the rules
(so far as relating to the procedure of that
House) at any time, in the same manner and
to the same extent as in the case of any other
rule of that House.
(2) TERMS
OF
THE
RESOLUTION.—For pur-
poses of subsection (a), the term ‘‘approval resolu-
tion’’ means only a joint resolution of the two
Houses of the Congress, providing in—
(A) the matter after the resolving clause of
which is as follows: ‘‘That the Congress ap-
proves the recommendations of the National
Commission on Health Care Reform as submit-
ted 
by 
the 
Commission 
on
llllllllllllll’’, the blank
137
space being filled in with the appropriate date;
and
(B) the title of which is as follows: ‘‘Joint
Resolution approving the recommendation of
the National Commission on Health Care Re-
form’’.
(3) INTRODUCTION
AND
REFERRAL.—On the
day on which the recommendation of the Commis-
sion is transmitted to the House of Representatives
and the Senate, an approval resolution with respect
to such recommendation shall be introduced (by re-
quest) in the House of Representatives by the Ma-
jority Leader of the House, for himself and the Mi-
nority Leader of the House, or by Members of the
House designated by the Majority Leader of the
House, for himself and the Minority Leader of the
House, or by Members of the House designated by
the Majority Leader and Minority Leader of the
House; and shall be introduced (by request) in the
Senate by the Majority Leader of the Senate, for
himself and the Minority Leader of the Senate, or
by Members of the Senate designated by the Major-
ity Leader and Minority Leader of the Senate. If ei-
ther House is not in session on the day on which
such recommendation is transmitted, the approval
138
resolution with respect to such recommendation shall
be introduced in the House, as provided in the pre-
ceding sentence, on the first day thereafter on which
the House is in session. The approval resolution in-
troduced in the House of Representatives and the
Senate shall be referred to the appropriate commit-
tees of each House.
(4) AMENDMENTS
PROHIBITED.—No amend-
ment to an approval resolution shall be in order in
either the House of Representatives or the Senate;
and no motion to suspend the application of this
subsection shall be in order in either House, nor
shall it be in order in either House for the Presiding
Officer to entertain a request to suspend the appli-
cation of this subsection by unanimous consent.
(5) PERIOD FOR COMMITTEE AND FLOOR CON-
SIDERATION.—
(A) IN GENERAL.—Except as provided in
subparagraph (B), if the committee or commit-
tees of either House to which an approval reso-
lution has been referred have not reported it at
the close of the 45th day after its introduction,
such committee or committees shall be auto-
matically discharged from further consideration
of the approval resolution and it shall be placed
139
on the appropriation calendar. A vote on final
passage of the approval resolution shall be
taken in each House on or before the close of
the 45th day after the approval resolution is re-
ported by the committees or committee of that
House to which it was referred, or after such
committee or committees have been discharged
from further consideration of the approval reso-
lution. If prior to the passage by one House of
an approval resolution of that House, that
House receives the same approval resolution
from the other House then—
(i) the procedure in that House shall
be the same as if no approval resolution
had been received from the other House;
but
(ii) the vote on final passage shall be
on the approval resolution of the other
House.
(B) COMPUTATION
OF
DAYS.—For pur-
poses of subparagraph (A), in computing a
number of days in either House, there shall be
excluded any day on which the House is not in
session.
140
(6) FLOOR CONSIDERATION IN THE HOUSE OF
REPRESENTATIVES.—
(A) MOTION TO PROCEED.—A motion in
the House of Representatives to proceed to the
consideration of an approval resolution shall be
highly privileged and not debatable. An amend-
ment to the motion shall not be in order, nor
shall it be in order to move to reconsider the
vote by which the motion is agreed to or dis-
agreed to.
(B) DEBATE.—Debate in the House of
Representatives on an approval resolution shall
be limited to not more than 20 hours, which
shall be divided equally between those favoring
and those opposing the bill or resolution. A mo-
tion further to limit debate shall not be debat-
able. It shall not be in order to move to recom-
mit an approval resolution or to move to recon-
sider the vote by which an approval resolution
is agreed to or disagreed to.
(C) MOTION
TO
POSTPONE.—Motions to
postpone, made in the House of Representatives
with respect to the consideration of an approval
resolution, and motions to proceed to the con-
141
sideration of other business, shall be decided
without debate.
(D) APPEALS.—All appeals from the deci-
sions of the Chair relating to the application of
the Rules of the House of Representatives to
the procedure relating to an approval resolution
shall be decided without debate.
(E) GENERAL RULES APPLY.—Except to
the extent specifically provided in the preceding
provisions of this paragraph, consideration of
an approval resolution shall be governed by the
Rules of the House of Representatives applica-
ble to other bills and resolutions in similar cir-
cumstances.
(7) FLOOR CONSIDERATION IN THE SENATE.—
(A) MOTION TO PROCEED.—A motion in
the Senate to proceed to the consideration of an
approval resolution shall be privileged and not
debatable. An amendment to the motion shall
not be in order, nor shall it be in order to move
to reconsider the vote by which the motion is
agreed to or disagreed to.
(B) GENERAL
DEBATE.—Debate in the
Senate on an approval resolution, and all debat-
able motions and appeals in connection there-
142
with, shall be limited to not more than 20
hours. The time shall be equally divided be-
tween, and controlled by, the Majority Leader
and the Minority Leader or their designees.
(C) DEBATE OF MOTIONS AND APPEALS.—
Debate in the Senate on any debatable motion
or appeal in connection with an approval resolu-
tion shall be limited to not more than 1 hour,
to be equally divided between, and controlled
by, the mover and the manager of the approval
resolution, except that in the event the manager
of the approval resolution is in favor of any
such motion or appeal, the time in opposition
thereto, shall be controlled by the Minority
Leader or his designee. Such leaders, or either
of them, may, from time under their control on
the passage of an approval resolution, allot ad-
ditional time to any Senator during the consid-
eration of any debatable motion or appeal.
(D) OTHER
MOTIONS.—A motion in the
Senate to further limit debate is not debatable.
A motion to recommit an approval resolution is
not in order.
143
(8) 
POINT
OF
ORDER
REQUIRING
SUPERMAJORITY
FOR
MODIFICATIONS
TO
REC-
OMMENDATION ONCE APPROVED.—
(A) IN GENERAL.—It shall not be in order
in the House of Representatives or the Senate
to consider any amendment to the provisions of
this Act except as provided in subparagraph
(B).
(B) WAIVER.—The point of order de-
scribed in subparagraph (A) may be waived or
suspended in the House of Representatives or
the Senate only, by the affirmative vote of
three-fifths of the Members duly chosen and
sworn.
Subtitle 
B—Demonstration
Projects on Alternative Financ-
ing and Delivery Systems
SEC. 
211. 
ESTABLISHMENT 
OF 
DEMONSTRATION
PROJECTS.
Not later than 1 year after the date of the enactment
of this Act, the Secretary of Health and Human Services
(in this subtitle referred to as the ‘‘Secretary’’) shall es-
tablish such demonstration projects as may be necessary
to test alternative methods for organizing the structure
144
of the health care financing and delivery system of the
United States.
SEC. 212. PROCESS.
(a) IN GENERAL.—In carrying out section 211, the
Secretary—
(1) may initiate demonstration projects under
this subtitle, and
(2) may seek applications from States desiring
to test alternative health care financing and delivery
systems within their jurisdictions.
(b) STATE APPLICATIONS.—
(1) IN GENERAL.—A State seeking approval of
a demonstration project under this subtitle shall file
an application in such form, in such manner, and at
such time as the Secretary may require.
(2) EVALUATION.—In evaluating an application
submitted under paragraph (1) for a project, the
Secretary shall take into account support for the
project by the citizens of a State as evidenced by the
enactment of legislation providing for implementa-
tion of an alternative health care financing and de-
livery system in every political subdivision of the
State.
145
(c) CONSULTATION.—Before making a final deter-
mination on approving a demonstration project under this
subtitle, the Secretary shall—
(1) consult with policy experts about any waiv-
ers necessary under section 215(a),
(2) consult with the Secretary of Labor and the
Attorney General about any waivers necessary under
subsections (b) and (c) of section 215, respectively,
(3) provide an opportunity for all parties that
would be affected by the demonstration project to
express their views, and
(4) in the case of a project initiated by the Sec-
retary, obtain the approval of the State regarding
any changes in the rules applicable to the State plan
approved under title XIX of the Social Security Act.
(d) NO INCREASE IN FEDERAL EXPENDITURES.—
The Secretary may not establish or approve a demonstra-
tion project under this subtitle unless the Secretary deter-
mines that the total amount expended by the Federal gov-
ernment under titles XVIII and XIX of the Social Security
Act for such project (other than amounts expended for the
evaluation of the projects under section 216(b)) will not
exceed the total amount that would have been expended
under such titles but for such project.
148
promotes the greatest efficiencies in the utilization
of expensive services and technology.
SEC. 214. SCOPE AND DURATION OF PROJECTS.
The demonstration projects conducted under this
subtitle shall be of such scope and duration as may be
necessary to test and evaluate the approach tested under
the project.
SEC. 215. WAIVERS OF CERTAIN LAWS.
(a) MEDICARE
AND MEDICAID LAWS.—The Sec-
retary may waive such provisions of titles XVIII (other
than provisions relating to the eligibility for, and the scope
of, benefits under such title) and XIX of the Social Secu-
rity Act as may be necessary to implement a demonstra-
tion project under this subtitle.
(b) ERISA.—The Secretary of Labor may waive sec-
tion 514(a) of the Employee Retirement Income Security
Act of 1974 (as that provision limits the application of
State laws to employee benefit plans) to the extent nec-
essary to permit a State to implement a demonstration
project under this subtitle.
(c) ANTITRUST LAWS.—
(1) IN GENERAL.—Subject to paragraph (2),
the Attorney General may waive such provisions
of—
(A) the Sherman Act,
149
(B) the Clayton Act, and
(C) the Federal Trade Commission Act,
as may be necessary to permit a State to implement
a demonstration project under this subtitle.
(2) DETERMINATION
REQUIRED.—A provision
specified in paragraph (1) may be waived only if the
Attorney General determines that the demonstration
project would reduce health care costs on a system-
wide basis.
SEC. 216. REPORTS AND EVALUATIONS.
(a) CONGRESSIONAL REPORTS.—The Secretary shall
submit to the Congress—
(1) annually a report on the status of each
demonstration project being conducted under this
subtitle, and
(2) a final report on each such project not later
than 1 year after the close of the project.
(b) INDEPENDENT EVALUATION.—
(1) IN GENERAL.—The Secretary shall arrange
for an independent evaluation of each demonstration
project conducted under this subtitle and for the
submission of the evaluation to the National Health
Care Reform Commission (established under section
201) not later than 1 year after the close of the
project.