I
103D CONGRESS
2D SESSION
H. R. 4024
To establish a national program of trained community health advisors to
assist the States in attaining the Healthy People 2000 Objectives.
IN THE HOUSE OF REPRESENTATIVES
MARCH 11, 1994
Mr. SANDERS (for himself, Mr. DELLUMS, Ms. EDDIE BERNICE JOHNSON of
Texas, Ms. PELOSI, Mr. PETERSON of Minnesota, Ms. VELA´ZQUEZ, Mr.
BEILENSON, Mr. OWENS, Mr. HOCHBRUECKNER, Mr. SCOTT, Mr. PAS-
TOR, and Mr. MCHALE) introduced the following bill; which was referred
to the Committee on Energy and Commerce
A BILL
To establish a national program of trained community health
advisors to assist the States in attaining the Healthy
People 2000 Objectives.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘National Community
Health Advisor Act’’.
SEC. 2. FINDINGS.
The Congress finds the following:
(1) Poverty, geographic isolation, cultural dif-
ferences, lack of transportation, low literacy, lack of
access to services and further difficulties resulting
from a lack of continuity of care, are barriers for
millions of low-income and underserved Americans in
the current health care delivery system.
(2) The Public Health Service has determined
that many health problems are rooted in poverty and
hit hardest at those least able to protect themselves.
(3) The Public Health Service has established
goals and objectives regarding improvements in the
health of the public by the year 2000. An evaluation
by the Service, entitled ‘‘Health United States 1992
and Healthy People 2000 Review’’, illustrates the
acute access problem faced by rural areas and the
inner cities. The evaluation cites the fact that sub-
urbs have the lowest death rates, while death rates
in rural counties are 12 percent higher and in large
core metropolitan counties, 19 percent higher.
(4) Discussions of health care reform focus al-
most exclusively on questions of how to extend
health insurance to the Nation’s 35–40 million unin-
sured and make services available while simulta-
neously bringing medical cost under control; how-
ever, it is imperative to correct the fundamental and
deep-rooted obstacles that low-income urban and
rural Americans confront when trying to access med-
ical care and preventive health services. For exam-
ple, in 1991, 19 million American women qualified
for mammography screening benefits through Medi-
care; however, only 670,000 (or less than 3 percent)
took advantage of this benefit.
(5) People who are local, indigenous members
and residents of underserved communities are
uniquely knowledgeable about their populations’
needs; where such individuals are already serving as
community health advisors, they communicate to
health and social service providers the needs of com-
munity members, provide quality health promotion
and disease prevention information to the commu-
nity and serve as the crucial link between their com-
munities and providers to increase utilization of
available preventive health services and to reach out
to communities to increase the effectiveness of the
health care delivery system, reduce preventable mor-
bidity and mortality, and improve the quality of life.
SEC. 
3. 
FORMULA 
GRANTS 
REGARDING 
COMMUNITY
HEALTH ADVISOR PROGRAMS.
(a) IN GENERAL.—In the case of each State (or en-
tity designated by a State under subsection (b)) that sub-
mits to the Secretary an application in accordance with
section 6 for a fiscal year, the Secretary of Health and
Human Services, acting through the Director of the Cen-
ters for Disease Control and Prevention, shall make an
award of financial assistance to the State or entity for the
development and operation of community health advisor
programs under section 4(b). The award shall consist of
the allotment determined under section 7 with respect to
the State, subject to section 12(b).
(b) DESIGNATED ENTITIES.—With respect to the
State involved, an entity other than the State may receive
an award under paragraph (1) only if the entity—
(1) is a public or nonprofit private academic or-
ganization (or other public or nonprofit private en-
tity); and
(2) has been designated by the State to carry
out the purpose described in such paragraph in the
State and to receive amounts under such paragraph
in lieu of the State.
(c) 
ROLE
OF
STATE
AGENCY
FOR
PUBLIC
HEALTH.—A funding agreement for an award under sub-
section (a) is that—
(1) if the applicant is a State, the award will
be administered by the State agency with the prin-
cipal responsibility for carrying out public health
programs; and
(2) if the applicant is an entity designated
under subsection (b), the award will be administered
in consultation with such State agency.
(d) STATEWIDE RESPONSIBILITIES; LIMITATION ON
EXPENDITURES.—
(1) STATEWIDE RESPONSIBILITIES.—A funding
agreement for an award under subsection (a) is that
the applicant involved will—
(A) operate a clearinghouse to maintain
and disseminate information on community
health advisor programs (and similar programs)
in the State, including information on develop-
ing and operating such programs, on training
individuals to participate in the programs, and
on evaluation of the programs;
(B) provide to community health advisor
programs in the State technical assistance in
training community health advisors under sec-
tion 5(g)(1); and
(C) coordinate the activities carried out in
the State under the award, including coordina-
tion between the various community health ad-
visor programs and coordination between such
programs and related activities of the State and
of other public or private entities.
(2) LIMITATION.—A funding agreement for an
award under subsection (a) is that the applicant in-
volved will not expend more than 15 percent of the
award in the aggregate for carrying out paragraph
(1) and for the expenses of administering the award
with respect to the State involved, including the
process of receiving payments from the Secretary
under the award, allocating the payments among the
entities that are to develop and operate the commu-
nity health advisor programs involved, and monitor-
ing compliance with the funding agreements made
under this Act by the applicant.
SEC. 4. REQUIREMENTS REGARDING COMMUNITY HEALTH
ADVISOR PROGRAMS.
(a) PURPOSE OF AWARD; HEALTHY PEOPLE 2000
OBJECTIVES.—
(1) IN GENERAL.—Subject to paragraph (2), a
funding agreement for an award under section 3 for
an applicant is that the purpose of the award is,
through community health advisor programs under
subsection (b), to assist the State involved in attain-
ing the Healthy People 2000 Objectives (as defined
in subsection (d).
(2) AUTHORITY REGARDING SELECTION OF PRI-
ORITY
OBJECTIVES.—With respect to compliance
with the agreement made under paragraph (1), an
applicant receiving an award under section 3 may,
from among the various Healthy People 2000 Objec-
tives, select one or more Objectives to be given prior-
ity in the operation of a community health advisor
program of the applicant, subject to the applicant
selecting such priorities in consultation with the en-
tity that is to carry out the program.
(b) REQUIREMENTS FOR PROGRAMS.—
(1) IN GENERAL.—A funding agreement for an
award under section 3 for an applicant is that, in
expending the award, the purpose described in sub-
section (a)(1) will be carried out in accordance with
the following:
(A) For each community for which the
purpose is to be carried out, the applicant will
establish a program in accordance with this
subsection.
(B) The program will be carried out in a
community only if the applicant has, under sec-
tion 5(a), identified the community as having a
significant need for the program.
(C) The program will be operated by a
public or nonprofit private entity with experi-
ence in providing health or health-related social
services to individuals who are underserved with
respect to such services.
(D) The services of the program, as speci-
fied in paragraph (2), will be provided prin-
cipally by community health advisors (as de-
fined in subsection (d)).
(2) AUTHORIZED
PROGRAM
SERVICES.—For
purposes of paragraph (1)(D), the services specified
in this paragraph for a program are as follows:
(A) The program will collaborate with
health care providers and related entities in
order to facilitate the provision of health serv-
ices and health-related social services (including
collaborating with local health departments,
community health centers, migrant health cen-
ters, rural health clinics, hospitals, physicians
and nurses, providers of health education, and
providers of social services).
(B) The program will provide public edu-
cation on health promotion and disease preven-
tion and facilitate the use of available health
services and health-related social services.
(C) The program will provide health-relat-
ed counseling.
(D) The program will provide referrals for
available health services and health-related so-
cial services.
(E) For the purpose of increasing the ca-
pacity of individuals to utilize health services
and health-related social services under Federal,
State, and local programs, the following condi-
tions will be met:
(i) The program will assist individuals
in establishing eligibility under the pro-
grams and in receiving the services or
other benefits of the programs.
(ii) The program will provide such
other services as the Secretary determines
to be appropriate, which services may in-
clude (but are not limited to) transpor-
tation and translation services.
(F) The program will provide outreach
services to inform the community of the avail-
ability of the services of the program.
(c) PRIORITY FOR MEDICALLY UNDERSERVED COM-
MUNITIES.—A funding agreement for an award under sec-
tion 3 is that the applicant involved will give priority to
developing and operating community health advisor pro-
grams for medically underserved communities.
(d) CERTAIN DEFINITIONS.—
(1) COMMUNITY HEALTH ADVISOR.—For pur-
poses of this Act, the term ‘‘community health advi-
sor’’ means an individual—
(A) who has demonstrated the capacity to
carry out one or more of the authorized pro-
gram services;
(B) who, for not less than 1 year, has been
a resident of the community in which the com-
munity health advisor program involved is to be
operated; and
(C) is a member of a socioeconomic group
to be served by the program.
(2) HEALTHY PEOPLE 2000 OBJECTIVES.—For
purposes of this Act, the term ‘‘Healthy People 2000
Objectives’’ means the objectives established by the
Secretary toward increasing the span of healthy life,
reducing health disparities among various popu-
lations, and providing access to preventive services,
which objectives apply to the health status of the
population of the United States for the year 2000.
(3) MEDICALLY UNDERSERVED COMMUNITY.—
For purposes of this Act, the term ‘‘medically under-
served community’’ means—
(A) a community that has a substantial
number of individuals who are members of a
medically underserved population, as defined in
section 330 of the Public Health Service Act; or
(B) a community a significant portion of
which is a health professional shortage area
designated under section 332 of such Act.
SEC. 5. ADDITIONAL AGREEMENTS.
(a) IDENTIFICATION
OF COMMUNITY NEEDS.—A
funding agreement for an award under section 3 that the
applicant involved will—
(1) identify the needs of the community in-
volved for the authorized program services;
(2) in identifying such needs, consult with
members of the community, with individuals and
programs that provide health services in the commu-
nity, and with individuals and programs that provide
health-related social services in the community; and
(3) consider such needs in carrying out a com-
munity health advisor program for the community.
(b) MATCHING FUNDS.—
(1) IN GENERAL.—With respect to the cost of
carrying out a community health advisor program, a
funding agreement for an award under section 3 is
that the applicant involved will make available (di-
rectly or through donations from public or private
entities) non-Federal contributions toward such cost
in an amount that is not less than 25 percent of
such cost.
(2) DETERMINATION
OF
AMOUNT
CONTRIB-
UTED.—
(A) Non-Federal contributions required in
paragraph (1) may be in cash or in kind, fairly
evaluated, including plant, equipment, or serv-
ices. Amounts provided by the Federal Govern-
ment, or services assisted or subsidized to any
significant extent by the Federal Government,
may not be included in determining the amount
of such non-Federal contributions.
(B) With respect to the State in which the
community health advisor program involved is
to be carried out, amounts provided by the
State in compliance with subsection (c) shall be
included in determining the amount of non-Fed-
eral contributions under paragraph (1).
(c) MAINTENANCE OF EFFORT.—With respect to the
purposes for which an award under section 3 is authorized
in this Act to be expended, the Secretary may make such
an award only if the State involved agrees to maintain
expenditures of non-Federal amounts for such purposes
at a level that is not less than the level of such expendi-
tures maintained by the State for the fiscal year preceding
the first fiscal year for which such an award is made with
respect to the State.
(d) CULTURAL CONTEXT OF SERVICES.—A funding
agreement for an award under section 3 for an applicant
is that the services of the community health advisor pro-
gram involved will be provided in the language and cul-
tural context most appropriate for the individuals served
by the program.
(e) NUMBER OF PROGRAMS PER AWARD; PROGRAMS
FOR URBAN AND RURAL AREAS.—A funding agreement
for an award under section 3 for an applicant is that the
number of community health advisor programs operated
in the State with the award will be determined by the Sec-
retary, except that (subject to section 4(b)(1)(B)) such a
program will be carried out in not less than one urban
area of the State, and in not less than one rural area of
the State.
(f) ONGOING SUPERVISION OF ADVISORS.—A fund-
ing agreement for an award under section 3 is that the
applicant involved will ensure that each community health
advisor program operated with the award provides for the
ongoing supervision of the community health advisors of
the program.
(g) CERTAIN EXPENDITURES.—
(1) 
TRAINING; 
CONTINUING
EDUCATION.—
Funding agreements for an award under section 3
include the following:
(A) The applicant involved will ensure
that, for each community health advisor pro-
gram operated with the award, a program is
carried out to train community health advisors
to provide the authorized program services, in-
cluding practical experiences in providing serv-
ices for health promotion and disease preven-
tion.
(B) The program of training will provide
for the continuing education of the community
health advisors.
(C) Not more than 15 percent of the
award will be expended for the program of
training.
(2) COMPENSATION.—With respect to compli-
ance with the agreements made under this Act, the
purposes for which an award under section 3 may be
expended include providing compensation for the
services of community health advisors.
(h) REPORTS TO SECRETARY; ASSESSMENT OF EF-
FECTIVENESS.—Funding agreements for an award under
section 3 for an applicant include the following:
(1) The applicant will ensure that, for each fis-
cal year for which a community health advisor pro-
gram receives amounts from the award, the program
will prepare a report describing the activities of the
program for such year, including—
(A) a specification of the number of indi-
viduals served by the program;
(B) a specification of the entities with
which the program has collaborated in carrying
out the purpose described in section 4(a)(1);
and
(C) an assessment of the extent of the ef-
fectiveness of the program in carrying out such
purpose.
(2) Such reports will include such additional in-
formation regarding the applicant and the programs
as the Secretary may require.
(3) The applicant will prepare the reports as a
single document and will submit the document to the
Secretary not later than February 1 of the fiscal
year following the fiscal year for which the reports
were prepared.
SEC. 6. APPLICATION FOR ASSISTANCE; STATE PLAN.
The Secretary may make an award under section 3
only if—
(1) an application for the award is submitted to
the Secretary;
(2) the application is submitted not later than
the date specified by the Secretary;
(3) the application contains each funding agree-
ment described in this Act;
(4) the application contains a State plan de-
scribing the purposes for which the award is to be
expended in the State, including a description of the
manner in which the applicant will comply with each
such funding agreement; and
(5) the application is in such form, is made in
such manner, and contains such agreements, assur-
ances, and information as the Secretary determines
to be necessary to carry out this Act.
SEC. 7. DETERMINATION OF AMOUNT OF ALLOTMENT.
(a) IN GENERAL.—For purposes of section 3, the al-
lotment under this section with respect to a State for a
fiscal year is the greater of—
(1) the sum of the respective amounts deter-
mined for the State under subsection (b) and sub-
section (c); and
(2) $500,000.
(b) AMOUNT RELATING TO POPULATION.—For pur-
poses of subsection (a), the amount determined under this
subsection is the product of—
(1) an amount equal to 50 percent of the
amount appropriated under section 12 for the fiscal
year and available for awards under section 3; and
(2) the percentage constituted by the ratio of—
(A) the number of individuals residing in
the State involved; to
(B) the sum of the respective amounts de-
termined for each State under subparagraph
(A).
(c) AMOUNT RELATING TO POVERTY LEVEL.—For
purposes of subsection (a), the amount determined under
this subsection is the product of—
(1) the amount determined under subsection
(b)(1); and
(2) the percentage constituted by the ratio of—
(A) the number of individuals residing in
the State whose income is at or below an
amount equal to 200 percent of the official pov-
erty line; to
(B) the sum of the respective amounts de-
termined for each State under subparagraph
(A).
SEC. 8. QUALITY ASSURANCE; COST-EFFECTIVENESS.
The Secretary shall establish guidelines for assuring
the quality of community health advisor programs (includ-
ing quality in the training of community health advisors)
and for assuring the cost-effectiveness of the programs.
A funding agreement for an award under section 3 is that
the applicant involved will carry out such programs in ac-
cordance with the guidelines.
SEC. 9. EVALUATIONS; TECHNICAL ASSISTANCE.
(a) EVALUATIONS.—The Secretary shall conduct
evaluations of community health advisor programs, and
may disseminate information developed as result of the
evaluations. In conducting such evaluations, the Secretary
shall determine whether the programs are in compliance
with the guidelines established under section 8.
(b) TECHNICAL ASSISTANCE.—The Secretary may
provide technical assistance to recipients of awards under
section 3 with respect to the planning, development, and
operation of community health advisor programs.
(c) GRANTS AND CONTRACTS.—The Secretary may
carry out this section directly or through grants, coopera-
tive agreements, or contracts.
(d) 
LIMITATION
ON
EXPENDITURES.—Of 
the
amounts appropriated under section 12 for a fiscal year,
the Secretary may reserve not more than 10 percent for
carrying out this section.
SEC. 10. RULE OF CONSTRUCTION REGARDING PROGRAMS
OF INDIAN HEALTH SERVICE.
This Act may not be construed as requiring the Sec-
retary to modify or terminate the program carried out by
the Director of the Indian Health Service and designated
by such Director as the Community Health Representative
Program. The Secretary shall ensure that support for such
Program is not supplanted by awards under section 3. In
communities in which both such Program and a commu-
nity health advisor program are being carried out, the Sec-
retary shall ensure that the community health advisor pro-
gram works in cooperation with, and as a complement to,
the Community Health Representative Program.
SEC. 11. DEFINITIONS.
For purposes of this Act:
(1) The term ‘‘authorized program services’’,
with respect to a community health advisor program,
means the services specified in section 4(b)(2).
(2) The term ‘‘community health advisor’’ has
the meaning given such term in section 4(d).
(3) The term ‘‘community health advisor pro-
gram’’ means a program carried out under section
4(b).
(4) The term ‘‘financial assistance’’, with re-
spect to an award under section 3, means a grant,
cooperative agreement, or a contract.
(5) The term ‘‘funding agreement’’ means an
agreement required as a condition of receiving an
award under section 3.
(6) The term ‘‘Healthy People 2000 Objectives’’
has the meaning given such term in section 4(d).
(7) The term ‘‘medically underserved commu-
nity’’ has the meaning given such term in section
4(d).
(8) The term ‘‘official poverty line’’ means the
official poverty line established by the Director of
the Office of Management and Budget and revised
by the Secretary in accordance with section 673(2)
of the Omnibus Budget Reconciliation Act of 1981.
(9) The term ‘‘Secretary’’ means the Secretary
of Health and Human Services.
(10) The term ‘‘State’’ means each of the sev-
eral States, the District of Columbia, and each of
the Commonwealth of Puerto Rico, American
Samoa, Guam, the Commonwealth of the Northern
Mariana Islands, the Virgin Islands, and the Trust
Territory of the Pacific Islands.
(11) The term ‘‘State involved’’, with respect to
an applicant for an award under section 3, means
the State in which the applicant is to carry out a
community health advisor program.
SEC. 12. FUNDING.
(a) AUTHORIZATION OF APPROPRIATIONS.—For the
purpose of carrying out this Act, there is authorized to
be appropriated $100,000,000 for each of the fiscal years
1995 through 2000.
(b) EFFECT OF INSUFFICIENT APPROPRIATIONS FOR
MINIMUM ALLOTMENTS.—
(1) IN GENERAL.—If the amounts made avail-
able under subsection (a) for a fiscal year are insuf-
ficient for providing each State (or entity designated
by the State pursuant to section 3, as the case may
be) with an award under section 3 in an amount
equal to or greater than the amount specified in sec-
tion 7(a)(2), the Secretary shall, from such amounts
as are made available under subsection (a), make
such awards on a discretionary basis.
(2) RULE OF CONSTRUCTION.—For purposes of
paragraph (1), awards under section 3 are made on
a discretionary basis if the Secretary determines
which States (or entities designated by States pursu-
ant to such section, as the case may be) are to re-
ceive such awards, subject to meeting the require-
ments of this Act for such an award, and the Sec-
retary determines the amount of such awards.
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HR 4024 IH——2
HR 4024 IH——3