I
103D CONGRESS
1ST SESSION
H. R. 1691
To provide universal access for all Americans to basic health care services
and long-term care services.
IN THE HOUSE OF REPRESENTATIVES
APRIL 5, 1993
Mr. ANDREWS of Maine introduced the following bill; which was referred joint-
ly to the Committees on Energy and Commerce, Ways and Means, Edu-
cation and Labor, Rules, Armed Services, Veterans’ Affairs, and Post Of-
fice and Civil Service
A BILL
To provide universal access for all Americans to basic health
care services and long-term care services.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘National Health Security Act of 1993’’.
(b) TABLE OF CONTENTS.—The table of contents for
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Statement of principles.
Sec. 3. General definitions.
TITLE I—ELIGIBILITY AND ENROLLMENT
Sec. 101. Eligibility and entitlement.
Sec. 102. Enrollment.
Sec. 103. Portability.
TITLE II—BENEFITS
Subtitle A—Health Care Services
Sec. 201. Covered health care services.
Sec. 202. Limitations and exclusions.
Sec. 203. Patient cost-sharing.
Subtitle B—Long-Term Care Services
Sec. 211. Covered long-term care services.
Sec. 212. Long-Term Care Services Assessment Commission.
Subtitle C—Modification of Services
Sec. 221. Modification of services covered under this Act.
TITLE III—FEDERAL AND STATE ADMINISTRATION
Subtitle A—Federal Administration
Sec. 301. Federal Health Board.
Sec. 302. Federal Health Advisory Council.
Sec. 303. Federal Health Priorities Council.
Sec. 304. Authorization of appropriations.
Subtitle B—State Administration
Sec. 311. State programs.
Sec. 312. Use of fiscal intermediaries.
Sec. 313. State waivers; managed care.
Sec. 314. State regional consortia.
Sec. 315. Grants to States.
Sec. 316. Technical assistance to States.
TITLE IV—FINANCING
Subtitle A—Health Budgets
Sec. 401. National health budget.
Sec. 402. Payments to States.
Sec. 403. State program budgets.
Subtitle B—Payments to Providers
Sec. 411. Payments to hospitals and other health care and long-term care insti-
tutions.
Sec. 412. Payments for practitioners services.
Sec. 413. Special nonphysician practitioner provisions.
Sec. 414. Mandatory assignment.
Subtitle C—Revenues
Sec. 421. Federal sources of revenues.
Sec. 422. Tax treatment of American Health Security Plan and private health
and long-term care insurance.
Sec. 423. Federal Health Trust Fund.
Sec. 424. State sources of revenues.
TITLE V—CONGRESSIONAL CONSIDERATION
Sec. 501. Rules governing congressional consideration.
TITLE VI—PRIVATE OPTIONS
Sec. 601. Private supplemental insurance.
Sec. 602. Option to purchase duplicative private insurance.
Sec. 603. Limits on private insurance.
TITLE VII—EXPANSION OF OUTCOMES RESEARCH AND
DELIVERY OF SERVICES IN UNDERSERVED AREAS
Sec. 701. Expansion of outcomes research.
Sec. 702. National health service corps.
Sec. 703. Community and migrant health centers.
TITLE VIII—MALPRACTICE REFORM
Sec. 801. Grants to States.
Sec. 802. Criteria for State malpractice reforms.
Sec. 803. Authorization of appropriations.
TITLE IX—EFFECTIVE DATES; TERMINATIONS; TRANSITION;
RELATION TO ERISA.
Sec. 901. Effective dates.
Sec. 902. Termination of other programs.
Sec. 903. Transition.
Sec. 904. Relation to ERISA.
SEC. 2. STATEMENT OF PRINCIPLES.
The principles of this Act are—
(1) to provide universal access to basic health
care services for all Americans regardless of their fi-
nancial and medical conditions;
(2) to establish the institutional and political
capacity to control the Nation’s escalating health
care costs and eliminate administrative waste;
(3) to ensure the portability of health care cov-
erage to all regions of the country;
(4) to build on the strengths of American fed-
eralism, with the Federal Government contributing
progressive financing and specifying minimum na-
tional standards while State governments supply ad-
ditional funding and administer the program with
the flexibility needed to address the specific concerns
of each region;
(5) to maintain the proven advantages of the
American health care delivery system, including pri-
vate practice, the freedom to choose among practi-
tioners, and superiority in biomedical technology;
(6) to encourage the effective use of preventive
and primary care;
(7) to enhance the autonomy of practitioners by
limiting the intrusiveness of government intervention
in the actual delivery of care;
(8) to promote the role of competition among
practitioners and to encourage innovation that re-
sults in higher quality and more efficient care;
(9) to reduce the incentives providers face to
perform medically unnecessary or inappropriate serv-
ices;
(10) to reinforce the public accountability of the
health care system, permitting explicit and open de-
liberation about the allocation of society’s resources
to health care; and
(11) to provide that all Americans share in the
responsibility of maintaining an efficient health care
system.
SEC. 3. GENERAL DEFINITIONS.
(a) IN GENERAL.—For purposes of this Act:
(1) The term ‘‘Board’’ means the Federal
Health Board established in section 301.
(2) The term ‘‘Advisory Council’’ means the
Federal Health Care Advisory Council established in
section 302.
(3) The term ‘‘Priorities Council’’ means the
Federal Health Priorities Council established in sec-
tion 303.
(4) The term ‘‘State program’’ means a State
health care program approved under section 311.
(5) The term ‘‘State’’ includes the District of
Columbia, the Commonwealth of Puerto Rico, the
United States Virgin Islands, Guam, American
Samoa, and the Commonwealth of the Northern
Mariana Islands.
(6) The term ‘‘Trust Fund’’ means the Federal
Health Trust Fund established in section 423.
(b) OTHER DEFINITIONS.—Except as otherwise pro-
vided, the definitions contained in section 1861 of the So-
cial Security Act (42 U.S.C. 1395x), as in effect on the
day before the date of the enactment of this Act, shall
apply in this Act.
TITLE I—ELIGIBILITY AND
ENROLLMENT
SEC. 101. ELIGIBILITY AND ENTITLEMENT.
(a) IN GENERAL.—Every individual who is a resident
of the United States and is a citizen or national of the
United States or lawful resident alien (as defined in sub-
section (d)) is entitled to health care services and long-
term care services covered under this Act in the State in
which the individual maintains a primary residence.
(b) TREATMENT OF CERTAIN NONIMMIGRANTS.—
(1) IN GENERAL.—The Board may make eligi-
ble for health care services and long-term care serv-
ices covered under this Act such classes of aliens ad-
mitted to the United States as nonimmigrants as the
Board may provide.
(2) CONSIDERATION.—In providing for eligi-
bility under paragraph (1), the Board shall consider
reciprocity in health care and long-term care services
offered 
to 
United 
States 
citizens 
who 
are
nonimmigrants in other foreign states, and such
other factors as the Board determines to be appro-
priate.
(c) TREATMENT
OF
OTHER
INDIVIDUALS.—The
Board may make eligible for health care services and long-
term care services covered under this Act other individuals
not described in subsection (a) or (b), and regulate the
nature of the eligibility of such individuals for the pur-
poses of fulfilling the following criteria:
(1) Preserving the public health of commu-
nities.
(2) Compensating States for the additional
health care financing burdens created by such indi-
viduals.
(3) Preventing adverse financial and medical
consequences of uncompensated care.
(4) Inhibiting travel and immigration to the
United States for the sole purpose of obtaining
health care services or long-term care services cov-
ered under this Act.
(d) LAWFUL RESIDENT ALIEN DEFINED.—For pur-
poses of this section, the term ‘‘lawful resident alien’’
means an alien lawfully admitted for permanent residence
and any other alien lawfully residing permanently in the
United States under color of law, including an alien with
lawful temporary resident status under section 210, 210A,
or 245A of the Immigration and Nationality Act (8 U.S.C.
1160, 1161, or 1255a).
SEC. 102. ENROLLMENT.
(a) IN GENERAL.—Each State program shall provide
a mechanism for enrollment of individuals entitled to bene-
fits under this Act and, in conjunction with such enroll-
ment, the issuance of a State health insurance card which
may be used for purposes of identification and processing
of claims for benefits under this Act.
(b) ENROLLMENT AT BIRTH OR IMMIGRATION.—The
mechanism under subsection (a) shall include a process
for the automatic enrollment of individuals at the time of
birth in the State or at the establishment of permanent
residence in the State, including at the time of immigra-
tion into the United States, other acquisition of lawful
resident status in the United States, or eligibility for other
individuals established under section 101(c).
SEC. 103. PORTABILITY.
To ensure continuous access to health care services
and long-term care services covered under this Act, each
State program—
(1) shall utilize a uniform claims form as devel-
oped by the Board;
(2) shall not impose any minimum period of
residence in the State, or waiting period, in excess
of 3 months before residents of the State are enti-
tled to such services;
(3) shall provide continuation of payment for
such services to individuals who have terminated
their residence in the State and established their
residence in another State, for the duration of any
waiting period imposed in the State of new residency
for establishing entitlement to such services; and
(4) shall provide for the payment for health
care services covered under this Act provided to indi-
viduals while temporarily absent from the State
based on the following principles:
(A) Payment for such health care services
is at the rate that is approved by the State pro-
gram in the State in which the services are pro-
vided, unless the States concerned agree to ap-
portion the cost between them in a different
manner.
(B)(i) Except as provided in clause (ii),
payment for such health care services provided
outside the United States is made on the basis
of the amount that would have been paid by the
State program for similar services rendered in
the State, with due regard, in the case of hos-
pital services, to the size of the hospital, stand-
ards of service, and other relevant factors.
(ii) Payment for services described under
clause (i) which are elective services may be
subject to prior consent of the agency that ad-
ministers and operates the State program if
such elective services are available on a sub-
stantially similar basis in the State.
(iii) For the purposes of this subpara-
graph, the term ‘‘elective services’’ means
health care services covered under this Act
other than services that are provided in an
emergency or in any other circumstance in
which medical care is required without delay.
TITLE II—BENEFITS
Subtitle A—Health Care Services
SEC. 201. COVERED HEALTH CARE SERVICES.
(a) IN GENERAL.—Every eligible individual is enti-
tled to have payment made for the health care services
covered under this Act by a participating provider if the
service is necessary or appropriate for the maintenance of
health or for the diagnosis or treatment of, or rehabilita-
tion following, injury, disability, or disease.
(b) SPECIFIC SERVICES.—Subject to limitations de-
scribed in section 202, health care services covered under
this Act are as follows:
(1) Inpatient and outpatient hospital care, in-
cluding 24-hour per day emergency services.
(2) Diagnostic and screening tests.
(3) Medical and other health services furnished
by health care professionals who are authorized to
provide such services under State law, including
medically necessary dental care.
(4) Preventive health care, including care for
well-defined causes of illness and injury (such as
breast, cervical, and colon cancer), immunizations
(for children, according to an immunization schedule
issued by the American Academy of Pediatrics), pre-
natal and postnatal care (according to guidelines of
the American College of Obstetrics and Gynecology,
and including prenatal and postnatal care coordina-
tion, and nutrition education), family planning serv-
ices, and well-baby and well-child care (including
physical examinations and vision, dental, hearing,
and developmental examinations).
(5) Prescription drugs, biologicals, and devices.
(6) Substance abuse treatment services, includ-
ing comprehensive residential treatment services for
pregnant women and women with children seeking
treatment for substance abuse.
(7) Inpatient and outpatient mental health
services to provide an active preventive, diagnostic,
therapeutic, or rehabilitative service with respect to
emotional or mental disorders.
(8) Hospice care for patients certified to be ter-
minally ill, provided under a State approved pro-
gram.
(9) Habilitation and rehabilitation services, in-
cluding physical, speech, and occupational therapies.
(10) Home medical equipment and prosthetic
devices prescribed by a licensed practitioner.
(11) Experimental treatment as deemed nec-
essary by the review of the Board and the State Ad-
visory Boards.
SEC. 202. LIMITATIONS AND EXCLUSIONS.
(a) NO LIMITS IN GENERAL.—Except as provided in
this section, section 203, and section 221, a State program
may not limit the amount, duration, or scope of health
care services covered under this Act.
(b) SPECIFIC EXCLUSIONS.—Health care services ex-
cluded from coverage under this Act include the following:
(1) Cosmetic surgery, except medically nec-
essary reconstruction.
(2) Certain amenities in inpatient facilities,
such as private rooms and other amenities deter-
mined by the Board, unless medically necessary.
SEC. 203. PATIENT COST-SHARING.
(a) IN GENERAL.—Except as provided in this section,
a State program may not impose cost-sharing for services
under this Act.
(b) ESTABLISHMENT
OF COST-SHARING SCHED-
ULE.—
(1) IN
GENERAL.—Co-payments and out-of-
pocket limits shall be established by the Board con-
sistent with paragraph (2). The Board shall base its
determinations on the following principles:
(A) Assurance of administrative simplicity
and efficiency.
(B) Maintenance of the fiscal integrity of
the public health insurance program.
(C) Deterrence of unnecessary use of serv-
ices.
(D) Encouragement of healthy behaviors.
(E) Encouragement of the use of preven-
tive services.
(F) Maximization of economic fairness.
(G) Minimization of financial barriers to
appropriate medical care.
(2) SPECIFICS.—In establishing co-payments
and out-of-pocket limits under paragraph (1)—
(A) there shall be no cost-sharing imposed
with respect to preventive health care (described
in section 201(b)(4)), and
(B) there shall no deductible for any serv-
ices.
(3) STUDIES OF MODIFICATIONS.—
(A) IN GENERAL.—The Priorities Council
shall study—
(i) whether the out-of-pocket limits
should be modified to take into account
family size and family composition,
(ii) whether the use of co-payments is
a cost-effective means of containing health
care costs and whether the use of co-pay-
ments is an excessive administrative bur-
den on health care providers and fiscal
providers 
(designated 
under 
section
311(b)(2)),
(iii) the effects of the continuation of
duplicative private insurance (as allowed in
section 602), upon the quality, access, and
cost of the public health insurance pro-
gram,
(iv) whether cost sharing require-
ments should be different for individuals
that engage in certain practices deemed to
increase the likelihood such individuals will
utilize more health care resources than in-
dividuals who do not engage in such prac-
tices.
(B) SPECIFIC
RECOMMENDATIONS.—The
Priorities Council within 2 years of the date de-
scribed in section 901(b)(1) shall issue rec-
ommendations regarding the studies described
in subparagraph (A). The recommendations
must balance the following goals:
(i) Preserve the fiscal integrity of the
public health insurance program.
(ii) Minimize the shifting between in-
dividuals and families of the burden of fi-
nancing the public program.
(iii) Encourage behaviors by govern-
ments, intermediaries, providers, and indi-
viduals that lead to reduced costs to the
health care system.
(3) REGULATIONS
BASED
ON
RECOMMENDA-
TIONS.—
(A) IN GENERAL.—The Board is author-
ized to promulgate regulations, as it deems ap-
propriate, for implementing the recommenda-
tions of the Priorities Council.
(B) MODIFICATIONS.—The Board is also
authorized to promulgate regulations to make
periodic adjustments for inflation to income cat-
egories, co-payments, and deductibles.
(C) EFFECT OF REGULATIONS.—The regu-
lations incorporating these modifications to the
cost sharing and out-of-pocket limits described
in this section shall have the force of law, un-
less within 60 days of the promulgation of the
regulations, the Congress enacts a disapproval
resolution under the procedures described in
section 501.
Subtitle B—Long-Term Care
Services
SEC. 211. COVERED LONG-TERM CARE SERVICES.
(a) IN GENERAL.—The Board, by regulation, shall
set standards for eligibility, long-term care services cov-
ered, cost-sharing, income protection, and case coordina-
tion, subject to the criteria described in the following sub-
sections.
(b) ELIGIBILITY.—
(1) IN GENERAL.—The Board shall determine
the standards for eligibility for institutional and for
home and community-based long-term care services
based on an individual’s ability to perform activities
of daily living (ADLs) and instrumental activities of
daily living (IADLs), and comparable cognitive or
behavioral impairments.
(2) DETERMINATION.—Eligibility for long-term
care services shall be based on a determination by
a case manager of the individual’s ability to perform
the minimum level of ADLs and IADLs, according
to the standard set by the Board.
(3) STANDARD.—The Board shall, pursuant to
recommendations by the Advisory Council and the
Long-Term Care Services Assessment Commission,
periodically make recommendations about the effi-
cacy of using deficits in ADLs and IADLs, or meas-
ures of comparable cognitive or behavioral impair-
ment, or both, to determine eligibility for long-term
care services.
(c) SERVICES COVERED.—
(1) IN GENERAL.—The Board shall determine
the long-term care services to be covered under this
Act to meet the long-term care needs of the eligible
population.
(2) MINIMUM SERVICES.—At a minimum, long-
term care services to be covered under this Act, sub-
ject to standards set by the Board, shall include:
(A) Home and community-based services,
such as nursing care and rehabilitative and re-
storative care.
(B) Nursing home care.
(C) Hospice care.
(D) Home medical equipment.
(E) Services for individuals with devel-
opmental disabilities and mental illness.
(d) COST SHARING.—The Board shall establish an
income-related cost-sharing schedule for individuals eligi-
ble for long-term care services covered under this Act, tak-
ing into account such factors as what out-of-nursing home
expenses would have been.
(e) INCOME PROTECTION.—
(1) IN GENERAL.—The Board shall reduce the
cost sharing to ensure that the income and assets of
the individual using long-term care services covered
under this Act are sufficient to enable such individ-
ual to retain a personal needs allowance sufficient—
(A) to cover all items needed in addition to
those provided by the long-term care facility,
(B) to maintain such individual’s primary
residence, and
(C) to maintain such individual’s independ-
ence once the individual no longer needs long-
term care services.
(2) SPOUSAL
PROTECTION, ETC.—The Board
shall reduce the cost sharing to ensure that the in-
come of the spouse, dependent, parent, or guardian
of the individual using long-term care services cov-
ered under this Act is not reduced below levels deter-
mined appropriate by the Board, but in no case less
than the spousal protection levels under title XIX of
the Social Security Act, as in effect on the day be-
fore the date of the enactment of this Act.
(f) CASE MANAGEMENT.—
(1) IN GENERAL.—The Board shall set stand-
ards for case coordination of long-term care services
covered under this Act.
(2) CASE COORDINATOR.—
(A) IN GENERAL.—Under the case coordi-
nation system, services shall be made available
to individuals through a case coordinator who
will be responsible for matching services to each
individual’s needs, and coordinating the delivery
of services.
(B) 
SPECIFIC
RESPONSIBILITIES.—The
specific responsibilities of the case coordinator
include:
(i) The assessment and periodic reas-
sessment of an individual’s need for serv-
ices, and the availability and efficacy of in-
formal services.
(ii) The development of plan of care
for the individual.
(iii) The authorization and coordina-
tion of services designed to meet an indi-
vidual’s unmet needs.
(g) EFFECT OF REGULATIONS.—The regulations in-
corporating the standards described in subsection (a) shall
have the force of law, unless within 60 days of the promul-
gation of the regulations, the Congress enacts a dis-
approval resolution under the procedures described in sec-
tion 501.
SEC. 212. LONG-TERM CARE SERVICES ASSESSMENT COM-
MISSION.
(a) ESTABLISHMENT.—Due to the seriousness of the
current problems in long-term care, the Director of the
Congressional Office of Technology Assessment (hereafter
in this section referred to as the ‘‘Director’’) shall provide
for the appointment of a special task force, to be known
as the ‘‘Long-Term Care Services Assessment Commis-
sion’’ (hereafter in this section referred to as the ‘‘Com-
mission’’).
(b) MEMBERSHIP.—The Commission shall consist of
10 individuals appointed for a seven-year term, beginning
on October 1, 1994. The membership of the Commission
shall include long-term care service providers, other health
and social service professionals, individuals skilled in the
conduct and interpretation of biomedical, health services,
and health economics research, and representatives of con-
sumers, the elderly, and the disabled. The Director shall
fill any vacancy in the membership of the Commission in
the same manner as the original appointment. The va-
cancy shall not affect the power of the remaining members
to execute the duties of the Commission.
(c) COMPENSATION.—All members of the Commis-
sion shall be reimbursed by the Board for travel and per
diem in lieu of subsistence expenses during the perform-
ance of duties of the Commission in accordance with sub-
chapter I of chapter 57 of title 5, United States Code.
(d) ORGANIZATION.—The Commission shall cease to
exist at the end of the 7-year term described in subsection
(b).
day of the fiscal year 2000 shall be transferred to
the Trust Fund.
(3) APPROPRIATION OF ADDITIONAL SUMS.—
For fiscal years beginning after September 30,
1999, there are hereby authorized to be appro-
priated, and are appropriated, to the Trust Fund
such additional sums as equal the amounts appro-
priated with respect to title XIX of the Social Secu-
rity Act, section 1079 of title 10, United States
Code (CHAMPUS), and chapter 89 of title 5, Unit-
ed States Code, as in effect for fiscal year 1999.
Such amount shall be adjusted each fiscal year by
the increase in the Consumer Price Index (as deter-
mined by the Department of Labor) for the previous
fiscal year.
(4) APPROPRIATION OF SUMS FOR ADMINISTRA-
TIVE
COSTS.—For fiscal years 1995, 1996, and
1997, there are hereby authorized to be appro-
priated, and are appropriated, to the Trust Fund
such additional sums as may be required to make
expenditures referred to in subsection (c)(2).
(5) RETURNED GRANT FUNDS.—Any returned
grant funds as described in section 316(a)(2) of this
Act shall be transferred to the Trust Fund.
(c) EXPENDITURES.—