110 
‘‘(i) increase minimum direct care reg-
istered nurse-to-patient ratios under this 
subsection to reduce the number of pa-
tients that may be assigned to each direct 
care nurse; or 
‘‘(ii) add minimum direct care reg-
istered nurse-to-patient ratios for units not 
referred to in paragraphs (1) and (2). 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals and registered nurses. 
‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 
‘‘(A) IN
GENERAL.—The Secretary may 
prescribe regulations requiring additional staff-
ing of direct care registered nurses, licensed vo-
cational or practice nurses, licensed psychiatric 
technicians, certified nursing or patient care as-
sistants, or other licensed or unlicensed ancil-
lary staff above the minimum registered nurse- 
to-patient ratios that is based on the assess-
ment of the individual patient’s nursing care 
needs, the individual patient’s nursing care 
plan, and acuity level. 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
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fected hospitals, registered nurses, and ancillary 
staff. 
‘‘(7) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.—Nothing in this title shall preempt State 
standards that the Secretary determines to be as 
stringent as Federal requirements for a staffing plan 
established under this title. Minimum direct care 
registered nurse-to-patient ratios established under 
this subsection shall not preempt State requirements 
that the Secretary determines are as stringent as to 
Federal requirements for direct care registered 
nurse-to-patient ratios established under this title. 
‘‘(8) EXEMPTION IN EMERGENCIES.—The re-
quirements established under this subsection shall 
not apply during a state of emergency if a hospital 
is requested or expected to provide an exceptional 
level of emergency or other medical services. If a 
hospital seeks to apply the exemption under this 
paragraph in response to a complaint filed against 
the hospital for a violation of the provisions of this 
title, the hospital must demonstrate that prompt and 
diligent efforts were made to maintain required 
staffing levels. The Secretary shall issue guidance to 
hospitals that describes situations that constitute a 
state of emergency for purposes of the exemption 
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under this paragraph and shall establish necessary 
penalties for violations of this paragraph consistent 
with section 3406. 
‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF-
ING PLAN.— 
‘‘(1) CONSIDERATIONS
IN
DEVELOPMENT
OF 
PLAN.—In developing the staffing plan, a hospital 
shall provide for direct care registered nurse-to-pa-
tient ratios above the minimum direct care reg-
istered nurse-to-patient ratios required under sub-
section (b) if appropriate based upon consideration 
of, at a minimum, the following factors: 
‘‘(A) The number of patients on a par-
ticular unit on a shift-by-shift basis. 
‘‘(B) The acuity level and nursing care 
plan of patients on a particular unit on a shift- 
by-shift basis. 
‘‘(C) The anticipated admissions, dis-
charges, and transfers of patients during each 
shift that impacts direct patient care. 
‘‘(D) Specialized experience required of di-
rect care registered nurses on a particular unit. 
‘‘(E) Staffing levels and services provided 
by licensed vocational or practical nurses, li-
censed psychiatric technicians, certified nurse 
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assistants, or other ancillary staff in meeting 
direct patient care needs not required by a di-
rect care registered nurse. 
‘‘(F) The level of familiarity with hospital 
practices, policies, and procedures by temporary 
agency direct care registered nurses used dur-
ing a shift. 
‘‘(G) Obstacles to efficiency in the delivery 
of patient care presented by physical layout. 
‘‘(2) DOCUMENTATION OF STAFFING.—A hos-
pital shall specify the system used to document ac-
tual staffing in each unit for each shift. 
‘‘(3) ANNUAL REEVALUATION OF PLAN.— 
‘‘(A) IN GENERAL.—A hospital shall annu-
ally evaluate its staffing plan in each unit in re-
lation to actual patient care requirements. 
‘‘(B) UPDATE.—A hospital shall update its 
staffing plan to the extent appropriate based on 
such evaluation. 
‘‘(4) TRANSPARENCY.— 
‘‘(A) IN GENERAL.—Any staffing plan or 
method used to create and evaluate acuity-level 
and adopted by a hospital under this section 
shall be transparent in all respects, including 
disclosure of detailed documentation of the 
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114 
methodology used to determine nursing staff-
ing, identifying each factor, assumption, and 
value used in applying such methodology. 
‘‘(B) PUBLIC
AVAILABILITY.—The Sec-
retary shall establish procedures to provide that 
the documentation submitted under subsection 
(d) is available for public inspection in its en-
tirety. 
‘‘(5) REGISTERED
NURSE
PARTICIPATION.—A 
staffing plan of a hospital— 
‘‘(A) shall be developed and subsequent re-
evaluations shall be conducted under this sub-
section on the basis of input from direct care 
registered nurses at the hospital from each unit 
or patient care area; and 
‘‘(B) where such nurses are represented 
through collective bargaining, shall require bar-
gaining with the applicable recognized or cer-
tified collective bargaining representative of 
such nurses. 
Nothing in this title shall be construed to permit 
conduct prohibited under the National Labor Rela-
tions Act or chapter 71 of title 5, United States 
Code. 
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‘‘(6) STAFFING
COMMITTEES.—If a hospital 
maintains a staffing committee, then the committee 
shall include at least one registered nurse from each 
hospital unit and shall be composed of at least 50 
percent direct care registered nurses. The staffing 
committee shall include meaningful representation of 
other direct care nonmanagement staff. Direct care 
registered nurses who serve on the committee shall 
be selected by other direct care registered nurses 
from their unit. Other direct care nonmanagement 
staff shall be selected by other direct care non-
management staff. Participation on staffing commit-
tees shall be considered a part of the employee’s reg-
ularly scheduled workweek. 
‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos-
pital shall submit to the Secretary its staffing plan and 
any annual updates under subsection (c)(3)(B). A feder-
ally operated hospital may submit its staffing plan 
through the department or agency operating the hospital. 
‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 
‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos-
pital shall post a uniform notice in a form specified by 
the Secretary in regulation that— 
‘‘(1) explains requirements imposed under sec-
tion 3401; 
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‘‘(D) a copy of each notice posted under 
subsection (a). 
‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
‘‘(B) registered nurses and their collective 
bargaining representatives (if any); and 
‘‘(C) the public under regulations estab-
lished by the Secretary, or in the case of a fed-
erally operated hospital, under section 552 of 
title 5, United States Code (commonly known 
as the Freedom of Information Act). 
‘‘(c) AUDITS.—The Secretary shall conduct periodic 
audits to ensure— 
‘‘(1) implementation of the staffing plan in ac-
cordance with this title; and 
‘‘(2) accuracy in records maintained under this 
section. 
‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 
NURSE STAFFING REQUIREMENTS. 
‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 
shall comply with minimum direct care licensed practical 
nurse staffing requirements that the Secretary establishes 
for units in hospitals. Such staffing requirements shall be 
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established not later than 18 months after the date of the 
enactment of this title, and shall be based on the study 
conducted under subsection (b). 
‘‘(b) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in 
hospitals. The Director may contract with a qualified enti-
ty or organization to carry out such study under this para-
graph. The Director shall consult with licensed practical 
nurses and organizations representing licensed practical 
nurses regarding the design and conduct of the study. 
‘‘(c) APPLICATION OF REGISTERED NURSE PROVI-
SIONS TO LICENSED PRACTICAL NURSE STAFFING RE-
QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 
and (6) of section 3401(b), paragraphs (1), (2), (3), and 
(4) of section 3401(c), and section 3402 shall apply to 
the establishment and application of direct care licensed 
practical nurse staffing requirements under this section 
pursuant to the additional staffing requirements under 
subsection (b)(3)(G) of section 3401 and in the same man-
ner that they apply to the establishment and application 
of direct care registered nurse-to-patient ratios under sec-
tions 3401 and 3402. 
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‘‘(d) EFFECTIVE DATE.—The requirements of this 
section shall take effect as soon as practicable, as deter-
mined by the Secretary, but not later than— 
‘‘(1) 2 years after the date of the enactment of 
this title; and 
‘‘(2) in the case of a hospital in a rural area 
(as defined in section 1886(d)(2)(D) of the Social 
Security Act), 4 years after the date of the enact-
ment of this title. 
‘‘(e) STUDY.—Not later than 1 year after the date 
of the enactment of this title, the Secretary, acting 
through the Director of the Agency for Healthcare Re-
search and Quality shall complete a study of registered 
and practical nurse staffing requirements in clinics and 
other outpatient settings, and its effects on patient care 
in outpatient settings. The Director may contract with a 
qualified entity or organization to carry out such study 
under this subsection. The Director shall consult with reg-
istered nurses and licensed practice nurses working in out-
patient settings, including professional nursing associa-
tions and labor organizations representing both registered 
and practice nurses working in outpatient settings regard-
ing the design and conduct of the study. 
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‘‘SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS. 
‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 
nurses have a duty and right to act based on their profes-
sional judgment in accordance with State nursing laws 
and regulations of the State in which the direct nursing 
care is being performed and to provide care in the exclu-
sive interests of the patients and to act as the patient’s 
advocate. 
‘‘(b) ACCEPTANCE
OF
PATIENT
CARE
ASSIGN-
MENTS.—The nurse is responsible for providing com-
petent, safe, therapeutic, and effective nursing care to as-
signed patients. Before accepting a patient assignment, a 
nurse shall— 
‘‘(1) have the necessary professional knowledge, 
judgment, skills, and ability to provide the required 
care; 
‘‘(2) determine using professional judgment in 
accordance with State nursing laws and regulations 
of the State in which the direct nursing care is being 
performed whether the nurse is competent to per-
form the nursing care required; and 
‘‘(3) determine whether acceptance of a patient 
assignment would expose the patient or nurse to risk 
of harm. 
‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 
A nurse may object to, or refuse to participate in, any 
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activity, policy, practice, assignment, or task if in good 
faith— 
‘‘(1) the nurse reasonably believes it to be in 
violation of section 3401 or 3403; or 
‘‘(2) the nurse is not prepared by education, 
training, or experience to fulfill the assignment with-
out compromising the safety of any patient or jeop-
ardizing the license of the nurse. 
‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL 
OF ASSIGNMENT BARRED.— 
‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE-
TALIATION.—No hospital shall discharge, retaliate, 
discriminate, or otherwise take adverse action in any 
manner with respect to any aspect of a nurse’s em-
ployment (as defined in section 3407), including dis-
charge, promotion, compensation, or terms, condi-
tions, or privileges of employment, based on the 
nurse’s refusal of a work assignment under sub-
section (c). 
‘‘(2) NO FILING OF COMPLAINT.—No hospital 
shall file a complaint or a report against a nurse 
with a State professional disciplinary agency because 
of the nurse’s refusal of a work assignment under 
subsection (c). 
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‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar-
gaining representative, or legal representative of any nurse 
who has been discharged, discriminated against, or retali-
ated against in violation of subsection (d)(1) or against 
whom a complaint or report has been filed in violation of 
subsection (d)(2) may (without regard to whether a com-
plaint has been filed under subsection (f) of this section 
or subsection (b) of section 3406) bring a cause of action 
in a United States district court. A nurse who prevails 
on the cause of action shall be entitled to one or more 
of the following: 
‘‘(1) Reinstatement. 
‘‘(2) Reimbursement of lost wages, compensa-
tion, and benefits. 
‘‘(3) Attorneys’ fees. 
‘‘(4) Court costs. 
‘‘(5) Other damages. 
‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 
collective bargaining representative, or other individual 
may file a complaint with the Secretary against a hospital 
that violates the provisions of this title. For any complaint 
filed, the Secretary shall— 
‘‘(1) receive and investigate the complaint; 
‘‘(2) determine whether a violation of this title 
as alleged in the complaint has occurred; and 
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‘‘(3) if such a violation has occurred, issue an 
order that the complaining nurse or individual shall 
not suffer any discharge, retaliation, discrimination, 
or other adverse action prohibited by subsection (d) 
or subsection (h). 
‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the establishment of a toll-free telephone hotline 
to provide information regarding the requirements 
under sections 3401 through 3403 and to receive re-
ports of violations of such section. 
‘‘(2) NOTICE TO PATIENTS.—A hospital shall 
provide each patient admitted to the hospital for in-
patient care with the hotline described in paragraph 
(1), and shall give notice to each patient that such 
hotline may be used to report inadequate staffing or 
care. 
‘‘(h) PROTECTION FOR REPORTING.— 
‘‘(1) PROHIBITION
ON
RETALIATION
OR
DIS-
CRIMINATION.—A hospital shall not discriminate or 
retaliate in any manner against any patient, em-
ployee, or contract employee of the hospital, or any 
other individual, on the basis that such individual, in 
good faith, individually or in conjunction with an-
other person or persons, has presented a grievance 
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or complaint, or has initiated or cooperated in any 
investigation or proceeding of any governmental en-
tity, regulatory agency, or private accreditation 
body, made a civil claim or demand, or filed an ac-
tion relating to the care, services, or conditions of 
the hospital or of any affiliated or related facilities. 
‘‘(2) GOOD FAITH DEFINED.—For purposes of 
this subsection, an individual shall be deemed to be 
acting in good faith if the individual reasonably be-
lieves— 
‘‘(A) the information reported or disclosed 
is true; and 
‘‘(B) a violation of this title has occurred 
or may occur. 
‘‘(i) 
PROHIBITION
ON
INTERFERENCE
WITH 
RIGHTS.— 
‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw-
ful for any hospital to— 
‘‘(A) interfere with, restrain, or deny the 
exercise, or attempt to exercise, by any person 
of any right provided or protected under this 
title; or 
‘‘(B) coerce or intimidate any person re-
garding the exercise or attempt to exercise such 
right. 
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125 
‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR 
PRACTICES.—It shall be unlawful for any hospital to 
discriminate or retaliate against any person for op-
posing any hospital policy, practice, or actions which 
are alleged to violate, breach, or fail to comply with 
any provision of this title. 
‘‘(3) PROHIBITION
ON
INTERFERENCE
WITH 
PROTECTED COMMUNICATIONS.—A hospital (or an 
individual representing a hospital) shall not make, 
adopt, or enforce any rule, regulation, policy, or 
practice which in any manner directly or indirectly 
prohibits, impedes, or discourages a direct care 
nurse from, or intimidates, coerces, or induces a di-
rect care nurse regarding, engaging in free speech 
activities or disclosing information as provided under 
this title. 
‘‘(4) PROHIBITION
ON
INTERFERENCE
WITH 
COLLECTIVE ACTION.—A hospital (or an individual 
representing a hospital) shall not in any way inter-
fere with the rights of nurses to organize, bargain 
collectively, and engage in concerted activity under 
section 7 of the National Labor Relations Act (29 
U.S.C. 157). 
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‘‘(j) NOTICE.—A hospital shall post in an appropriate 
location in each unit a conspicuous notice in a form speci-
fied by the Secretary that— 
‘‘(1) explains the rights of nurses, patients, and 
other individuals under this section; 
‘‘(2) includes a statement that a nurse, patient, 
or other individual may file a complaint with the 
Secretary against a hospital that violates the provi-
sions of this title; and 
‘‘(3) provides instructions on how to file such a 
complaint. 
‘‘(k) EFFECTIVE DATE.— 
‘‘(1) REFUSAL; RETALIATION; CAUSE
OF
AC-
TION.— 
‘‘(A) 
IN
GENERAL.—Subsections 
(c) 
through (e) shall apply to objections and refus-
als occurring on or after the effective date of 
the provision of this title to which the objection 
or refusal relates. 
‘‘(B) EXCEPTION.—Subsection (c)(2) shall 
not apply to objections or refusals in any hos-
pital before the requirements of section 3401(a) 
or 3403(a), as applicable, apply to that hos-
pital. 
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127 
‘‘(2) PROTECTIONS
FOR
REPORTING.—Sub-
section (h)(1) shall apply to actions occurring on or 
after the effective date of the provision to which the 
violation relates, except that such subsection shall 
apply to initiation, cooperation, or participation in 
an investigation or proceeding on or after the date 
of enactment of this title. 
‘‘(3) NOTICE.—Subsection (j) shall take effect 
18 months after the date of enactment of this title. 
‘‘SEC. 3405. ENFORCEMENT. 
‘‘(a) IN GENERAL.—The Secretary shall enforce the 
requirements and prohibitions of this title in accordance 
with this section. 
‘‘(b) PROCEDURES
FOR RECEIVING
AND INVES-
TIGATING COMPLAINTS.—The Secretary shall establish 
procedures under which— 
‘‘(1) any person may file a complaint alleging 
that a hospital has violated a requirement or a pro-
hibition of this title; and 
‘‘(2) such complaints shall be investigated by 
the Secretary. 
‘‘(c) REMEDIES.—If the Secretary determines that a 
hospital has violated a requirement of this title, the Sec-
retary— 
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‘‘(1) shall require the facility to establish a cor-
rective action plan to prevent the recurrence of such 
violation; and 
‘‘(2) may impose civil money penalties, as de-
scribed in subsection (d). 
‘‘(d) CIVIL PENALTIES.— 
‘‘(1) IN GENERAL.—In addition to any other 
penalties prescribed by law, the Secretary may im-
pose civil penalties as follows: 
‘‘(A) HOSPITAL LIABILITY.—The Secretary 
may impose on a hospital found to be in viola-
tion of this title a civil money penalty of— 
‘‘(i) not more than $25,000 for the 
first knowing violation of this title by such 
hospital; and 
‘‘(ii) not more than $50,000 for any 
subsequent knowing violation of this title 
by such hospital. 
‘‘(B) INDIVIDUAL
LIABILITY.—The Sec-
retary may impose on an individual who— 
‘‘(i) is employed by a hospital found 
by the Secretary to have violated this title; 
and 
‘‘(ii) knowingly violates this title, 
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a civil money penalty of not more than $20,000 
for each such violation by the individual. 
‘‘(2) PROCEDURES.—The provisions of section 
1128A of the Social Security Act (other than sub-
sections (a) and (b)) shall apply with respect to a 
civil money penalty or proceeding under this sub-
section in the same manner as such provisions apply 
with respect to a civil money penalty or proceeding 
under such section 1128A. 
‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(1) INTERNET WEBSITE.—The Secretary shall 
publish on the internet website of the Department of 
Health and Human Services the names of hospitals 
on which a civil money penalty has been imposed 
under this section, the violation for which such pen-
alty was imposed, and such additional information 
as the Secretary determines appropriate. 
‘‘(2) CHANGE OF OWNERSHIP.—With respect to 
a hospital that had a change of ownership, as deter-
mined by the Secretary, penalties imposed on the 
hospital while under previous ownership shall no 
longer be published by the Secretary pursuant to 
paragraph (1) after the 1-year period beginning on 
the date of change of ownership. 
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130 
‘‘(f) USE OF FUNDS.—Funds collected by the Sec-
retary pursuant to this section are authorized to be appro-
priated to carry out this title. 
‘‘SEC. 3406. DEFINITIONS. 
‘‘For purposes of this title: 
‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 
means the determination, using a hospital acuity 
measurement tool that has been developed and es-
tablished in coordination with direct care registered 
nurses and made transparent pursuant to section 
3401(c)(4), of nursing care requirements, based on 
the assigned direct care registered nurse’s profes-
sional judgment of— 
‘‘(A) the severity and complexity of an in-
dividual patient’s illness or injury; 
‘‘(B) the need for specialized equipment; 
and 
‘‘(C) the intensity of nursing interventions 
required. 
‘‘(2) COMPETENCE.—The term ‘competence’ or 
‘competent’ means the satisfactory application of the 
duties and responsibilities of a registered nurse in 
providing nursing care to specific patient popu-
lations and for acuity levels for each patient care 
unit or area pursuant to the State nursing laws and 
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regulations of the State in which the direct nursing 
care is being performed. 
‘‘(3) 
DIRECT
CARE
LICENSED
PRACTICAL 
NURSE.—The term ‘direct care licensed practical 
nurse’ means an individual who has been granted a 
license by at least one State to practice as a licensed 
practical nurse or a licensed vocational nurse and 
who provides bedside care for one or more patients. 
‘‘(4) DIRECT CARE REGISTERED NURSE.—The 
term ‘direct care registered nurse’ means an indi-
vidual who has been granted a license by at least 
one State to practice as a registered nurse and who 
provides bedside care for one or more patients. 
‘‘(5) EMPLOYMENT.—The term ‘employment’ 
includes the provision of services under a contract or 
other arrangement. 
‘‘(6) HOSPITAL.—The term ‘hospital’ has the 
meaning given that term in section 1861(e) of the 
Social Security Act. 
‘‘(7) NURSE.—The term ‘nurse’ means any di-
rect care registered nurse or direct care licensed 
practice nurse (as the case may be), regardless of 
whether or not the nurse is an employee. 
‘‘(8) NURSING CARE PLAN.—The term ‘nursing 
care plan’ means a plan developed by the assigned 
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direct care registered nurse (in accordance with 
nursing law in the State in which the nursing care 
is performed) that indicates the nursing care to be 
given to individual patients that— 
‘‘(A) considers the acuity level of the pa-
tient; 
‘‘(B) is developed in coordination with the 
patient, the patient’s family, or other represent-
atives when appropriate, and staff of other dis-
ciplines involved in the care of the patient; 
‘‘(C) reflects all elements of the nursing 
process; and 
‘‘(D) recommends the number and skill 
mix of additional licensed and unlicensed direct 
care staff needed to fully implement the nursing 
care plan. 
‘‘(9) PROFESSIONAL
JUDGMENT.—The term 
‘professional judgment’ means, in accordance with 
State nursing laws and regulations of the State in 
which the direct nursing care is being performed, the 
direct care registered nurse’s application of knowl-
edge, expertise, and experience in conducting a com-
prehensive nursing assessment of each patient and 
in making independent decisions about patient care 
including the need for additional staff. 
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‘‘(10) STAFFING
PLAN.—The term ‘staffing 
plan’ means a staffing plan required under section 
3401. 
‘‘(11) STATE OF EMERGENCY.—The term ‘state 
of emergency’— 
‘‘(A) means a state of emergency that is 
an unpredictable or unavoidable occurrence at 
an unscheduled or unpredictable interval, relat-
ing to health care delivery and requiring imme-
diate medical interventions and care; and 
‘‘(B) does not include a state of emergency 
that results from a labor dispute in the health 
care industry or consistent understaffing. 
‘‘SEC. 3407. RULE OF CONSTRUCTION. 
‘‘Nothing in this title shall be construed to authorize 
disclosure of private and confidential patient information, 
if such disclosure is not authorized or required by other 
applicable law.’’. 
(b) RECOMMENDATIONS TO CONGRESS.—Not later 
than 1 year after the date of enactment of this Act, the 
Secretary of Health and Human Services shall submit to 
Congress a report containing recommendations for ensur-
ing that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXXIV of the Public 
Health Service Act, as added by subsection (a). 
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(c) REPORT BY HRSA.— 
(1) IN GENERAL.—Not later than 2 years after 
the date of enactment of this Act, the Administrator 
of the Health Resources and Services Administra-
tion, in consultation with the National Health Care 
Workforce Commission, shall submit to Congress a 
report regarding the relationship between nurse 
staffing levels and nurse retention in hospitals. 
(2) UPDATED REPORT.—Not later than 5 years 
after the date of enactment of this Act, the Adminis-
trator of the Health Resources and Services Admin-
istration, in consultation with the National Health 
Care Workforce Commission, shall submit to Con-
gress an update of the report submitted under para-
graph (1). 
(d) ENFORCEMENT
OF REQUIREMENTS THROUGH 
FEDERAL PROGRAMS.— 
(1) MEDICARE PROGRAM.—Section 1866(a)(1) 
of the Social Security Act (42 U.S.C. 1395cc(a)(1)) 
is amended— 
(A) in subparagraph (X), by striking ‘‘, 
and’’ and inserting a comma; 
(B) in subparagraph (Y), by striking the 
period at the end and inserting ‘‘, and’’; and 
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(C) by inserting after subparagraph (Y) 
the following new subparagraph: 
‘‘(Z) in the case of a hospital, to comply 
with the provisions of title XXXIV of the Public 
Health Service Act.’’. 
(2) MEDICAID PROGRAM.—Section 1902(a) of 
the Social Security Act (42 U.S.C. 1396a(a)) is 
amended— 
(A) by striking ‘‘and’’ at the end of para-
graph (82); 
(B) by striking the period at the end of 
paragraph (83) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (83) the 
following new paragraph: 
‘‘(84) provide that any hospital that receives a 
payment under such plan comply with the provisions 
of title XXXIV of the Public Health Service Act (re-
lating to minimum direct care registered nurse staff-
ing requirements).’’. 
(e) NURSING HOMES.—No later than one year after 
enactment of this Act, the Secretary of Health and 
Human Services shall promulgate a rule for minimum 
staffing standards for skilled nursing facilities under the 
Medicare program and for nursing facilities under the 
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Medicaid program that align with the standards set in this 
section. 
SEC. 134. ENHANCEMENTS FOR REDUCED COST-SHARING. 
(a) IN GENERAL.—Section 1402 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18071) is 
amended— 
(1) in subsection (b)(1), by striking ‘‘silver’’ 
and inserting ‘‘gold’’; 
(2) by amending subsection (c)(1)(B) to read as 
follows: 
‘‘(B) COORDINATION
WITH
ACTUARIAL 
LIMITS.—The Secretary shall ensure the reduc-
tion under this paragraph shall not result in the 
plan’s share of the total allowed costs of bene-
fits provided under the plan becoming less 
than— 
‘‘(i) 95 percent in the case of an eligi-
ble insured described in paragraph (2)(A); 
‘‘(ii) 90 percent in the case of an eli-
gible 
insured 
described 
in 
paragraph 
(2)(B); and 
‘‘(iii) 85 percent in the case of an eli-
gible 
insured 
described 
in 
paragraph 
(2)(C).’’; and 
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(3) by amending subsection (c)(2) to read as 
follows: 
‘‘(2) ADDITIONAL REDUCTION.—The Secretary 
shall establish procedures under which the issuer of 
a qualified health plan to which this section applies 
shall further reduce cost-sharing under the plan in 
a manner sufficient to— 
‘‘(A) in the case of an eligible insured 
whose household income is not less than 100 
percent but not more than 200 percent of the 
poverty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 95 
percent of such costs; 
‘‘(B) in the case of an eligible insured 
whose household income is more than 200 per-
cent but not more than 300 percent of the pov-
erty line for a family of the size involved, in-
crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 90 
percent of such costs; and 
‘‘(C) in the case of an eligible insured 
whose household income is more than 300 per-
cent but not more than 400 percent of the pov-
erty line for a family of the size involved, in-
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crease the plan’s share of the total allowed 
costs of benefits provided under the plan to 85 
percent of such costs.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this subsection shall apply to plan years beginning after 
December 31, 2019. 
(c) FUNDING.—Section 1402 of the Patient Protec-
tion and Affordable Care Act (42 U.S.C. 18071) is amend-
ed by adding at the end the following new subsection: 
‘‘(g) FUNDING.—Out of any funds in the Treasury 
not otherwise appropriated, there are appropriated to the 
Secretary such sums as may be necessary for payments 
under this section.’’. 
SEC. 135. REPEAL OF BONUS PAYMENTS FOR MEDICARE 
ADVANTAGE PLANS. 
Section 1853(o) of the Social Security Act (42 U.S.C. 
1395w–23(o)) is repealed. 
TITLE II—TAX PROVISIONS 
SEC. 201. SUNSET OF PUBLIC LAW 115–97. 
(a) IN GENERAL.—All provisions of, and amend-
ments made by, Public Law 115–97 shall not apply to cal-
endar, taxable, plan, or limitation years beginning after 
December 31, 2019. 
(b) APPLICATION OF CERTAIN LAWS.—The Internal 
Revenue Code of 1986 shall be applied and administered 
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to years described in subsection (a) as if the provisions 
and amendments described in subsection (a) had never 
been enacted. 
SEC. 202. SURTAX. 
There is hereby imposed a tax of 5 percent on the 
adjusted gross income of each taxpayer to the extent such 
income exceeds $500,000. 
SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE-
DENT. 
(a) IN GENERAL.—Section 1014 of the Internal Rev-
enue Code of 1986 is amended by striking ‘‘person, be’’ 
and all that follows through the period at the end and 
inserting the following: ‘‘person, be the basis in the hands 
of the decedent.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section to property acquired or passed after the date 
of enactment of this Act. 
SEC. 204. MEDICARE PAYROLL TAX. 
(a) IN GENERAL.—Section 3101(b)(2) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘0.9 per-
cent’’ and inserting ‘‘4 percent’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
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SEC. 205. NET INVESTMENT INCOME TAX. 
(a) IN GENERAL.—Section 1411(a) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘3.8 per-
cent’’ each place such term appears and inserting ‘‘6.9 
percent’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBU-
TIONS TO HEALTH SAVINGS ACCOUNTS. 
Section 223(b) of the Internal Revenue Code of 1986 
is amended by adding at the end the following new para-
graph: 
‘‘(9) TERMINATION OF DEDUCTION.—Notwith-
standing any other provision of this subsection, the 
monthly limitation for any month beginning after 
December 31, 2023, is zero.’’. 
SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND 
CIGARETTES AND OTHER TOBACCO PROD-
UCTS. 
(a) SMALL CIGARS.—Section 5701(a)(1) of the Inter-
nal Revenue Code of 1986 is amended by striking 
‘‘$50.33’’ and inserting ‘‘$100.66’’. 
(b) CIGARETTES.—Section 5701(b) of such Code is 
amended— 
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‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE 
SINGLE-USE
UNITS.—On discrete single-use units, 
$107.65 per each 1,000 single-use units.’’. 
(2) 
DISCRETE
SINGLE-USE
UNIT.—Section 
5702(m) of such Code is amended— 
(A) in paragraph (1), by striking ‘‘or chew-
ing tobacco’’ and inserting ‘‘chewing tobacco, 
discrete single-use unit’’; 
(B) in paragraphs (2) and (3), by inserting 
‘‘that is not a discrete single-use unit’’ before 
the period in each such paragraph; and 
(C) by adding at the end the following: 
‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 
‘discrete single-use unit’ means any product con-
taining tobacco that— 
‘‘(A) is not intended to be smoked; and 
‘‘(B) is in the form of a lozenge, tablet, 
pill, pouch, dissolvable strip, or other discrete 
single-use or single-dose unit’’. 
SEC. 208. EXCISE TAX ON ALCOHOL. 
(a) DISTILLED SPIRITS.—Section 5001(a)(1) of the 
Internal Revenue Code of 1986 is amended by striking 
‘‘$13.50’’ and inserting ‘‘$16.00’’. 
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(b) WINE.—(1) Section 5041(b)(1) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘$1.07 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gallon’’. 
(2) Section 5041(b)(2) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘$1.57 per wine gallon’’ 
and inserting ‘‘$16.00 per proof gallon’’. 
(3) Section 5041(b)(3) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘$3.15 per wine gallon’’ 
and inserting ‘‘$16.00 per proof gallon’’. 
(4) Section 5041(b)(4) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘$3.40 per wine gallon’’ 
and inserting ‘‘$16.00 per proof gallon’’. 
(5) Section 5041(b)(5) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘$3.30 per wine gallon’’ 
and inserting ‘‘$16.00 per proof gallon’’. 
(6) Section 5041(b)(3) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘$22.6 cents per wine gal-
lon’’ and inserting ‘‘$16.00 per proof gallon’’. 
(c) BEER.—Section 5051(B) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 
and inserting ‘‘$16 per proof gallon’’. 
SEC. 209. TAX ON SUGARED DRINKS. 
(a) IN GENERAL.—Subchapter D of chapter 32 of the 
Internal Revenue Code of 1986 is amended by inserting 
after part I the following new part: 
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‘‘PART II—SUGAR-SWEETENED BEVERAGES 
‘‘Sec. 4171. Imposition of tax. 
‘‘Sec. 4172. Definitions. 
‘‘Sec. 4173. Special rules. 
‘‘SEC. 4171. IMPOSITION OF TAX. 
‘‘(a) IN GENERAL.—There is hereby imposed a tax 
on the sale or transfer of any specified sugar-sweetened 
beverage product by the manufacturer, producer, or im-
porter thereof. 
‘‘(b) RATE OF TAX.—The rate of tax imposed under 
subsection (a) shall be equal to one cent per 4.2 grams 
of caloric sweetener contained in such specified sugar- 
sweetened beverage product. 
‘‘(c) PERSONS LIABLE
FOR TAX.—The manufac-
turer, producer, or importer referred to in subsection (a) 
shall be liable for the tax imposed by such subsection. 
‘‘SEC. 4172. DEFINITIONS. 
‘‘(a) SPECIFIED
SUGAR-SWEETENED
BEVERAGE 
PRODUCT.—For purposes of this part— 
‘‘(1) IN GENERAL.—For purposes of this part, 
the term ‘specified sugar-sweetened beverage prod-
uct’ means— 
‘‘(A) any liquid intended for human con-
sumption which contains a caloric sweetener, 
and 
‘‘(B) any liquid, or solid mixture of ingre-
dients, which— 
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‘‘(i) contains a caloric sweetener, and 
‘‘(ii) is intended for use as an ingre-
dient in a liquid described in subparagraph 
(A). 
‘‘(2) EXCEPTIONS.—The following shall not be 
treated as liquids described in paragraph (1)(A): 
‘‘(A) Any liquid the primary ingredients of 
which are milk or soy, rice, or similar plant- 
based milk substitute. 
‘‘(B) Any liquid composed entirely of one 
or more of the following: 
‘‘(i) The original liquid resulting from 
the pressing of fruit or vegetables. 
‘‘(ii) The liquid resulting from the re-
constitution of fruit or vegetable juice con-
centrate. 
‘‘(iii) The liquid resulting from the 
restoration of water to dehydrated fruit or 
vegetable juice. 
‘‘(C) Infant formula. 
‘‘(D) Any liquid products manufactured for 
use as— 
‘‘(i) an oral nutritional therapy for 
persons who cannot absorb or metabolize 
dietary nutrients from food or beverages, 
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‘‘(ii) a source of necessary nutrition 
used due to a medical condition, or 
‘‘(iii) an oral electrolyte solution for 
infants and children formulated to prevent 
dehydration due to illness. 
‘‘(E) Any liquid with respect to which tax 
is imposed under chapter 51 (relating to dis-
tilled spirits, wines, and beer) or under section 
7652 by reason of the tax imposed under chap-
ter 51 being imposed on like articles of domes-
tic manufacture. 
‘‘(b) CALORIC SWEETENER.—For purposes of this 
part, the term ‘caloric sweetener’ means monosaccharides, 
disaccharides, and high-fructose corn syrup. 
‘‘SEC. 4173. SPECIAL RULES. 
‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 
of any specified sugar-sweetened beverage product which 
is manufactured or produced by including one or more 
other specified sugar-sweetened beverage products, no tax 
shall be imposed under this section on any caloric sweet-
ener contained in the resulting specified sugar-sweetened 
beverage product if tax was previously imposed under this 
section on such caloric sweetener when contained in the 
specified sugar-sweetened beverage product so included. 
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‘‘(b) INFLATION ADJUSTMENT.—In the case of any 
sale after December 31, 2015, the one cent amount in sec-
tion 4171(b) shall be increased by an amount equal to— 
‘‘(1) such amount, multiplied by 
‘‘(2) the cost-of-living adjustment determined 
under section 1(f)(3) for the calendar year in which 
such sale occurs, determined by substituting ‘cal-
endar year 2014’ for ‘calendar year 1992’ in sub-
paragraph (B) thereof. 
Any increase determined under this subsection shall be 
rounded to the nearest multiple of one-tenth of a cent.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 4221(a) is amended by adding at 
the end the following: ‘‘Paragraphs (1), (4), (5), and 
(6) shall not apply to the tax imposed under section 
4171.’’. 
(2) The table of parts for subchapter D of 
chapter 32 of such Code is amended by inserting 
after the item relating to part I the following new 
item: 
‘‘PART II—SUGAR-SWEETENED BEVERAGES’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on the date of the enactment of this 
Act. 
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