I 
112TH CONGRESS 
2D SESSION 
H. R. 6352 
To amend title XVIII of the Social Security Act to provide for the distribution 
of additional residency positions, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 2, 2012 
Mr. SCHOCK (for himself and Ms. SCHWARTZ) introduced the following bill; 
which was referred to the Committee on Ways and Means, and in addi-
tion to the Committee on Energy and Commerce, for a period to be sub-
sequently determined by the Speaker, in each case for consideration of 
such provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for the distribution of additional residency positions, and 
for other purposes. 
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 ‘‘Resident Physician 
Shortage Reduction and Graduate Medical Education Ac-
countability and Transparency Act’’. 
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SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI-
TIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 
(8), and (9)’’; 
(3) in paragraph (7)(E), by inserting ‘‘para-
graph (9),’’ after ‘‘paragraph (8),’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY 
POSITIONS.— 
‘‘(A) 
ADDITIONAL
RESIDENCY
POSI-
TIONS.— 
‘‘(i) IN GENERAL.—For each of fiscal 
years 2013 through 2017 (and succeeding 
fiscal years if the Secretary determines 
that there are additional residency posi-
tions available to distribute under clause 
(iv)(II)), the Secretary shall, subject to 
clause (ii) and subparagraph (D), increase 
the otherwise applicable resident limit for 
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each qualifying hospital that submits a 
timely application under this subparagraph 
by such number as the Secretary may ap-
prove for portions of cost reporting periods 
occurring on or after July 1 of the fiscal 
year of the increase. 
‘‘(ii) NUMBER
AVAILABLE
FOR
DIS-
TRIBUTION.—For each such fiscal year, 
the Secretary shall determine the total 
number of additional residency positions 
available for distribution under clause (i) 
in accordance with the following: 
‘‘(I) ALLOCATION TO HOSPITALS 
ALREADY OPERATING OVER RESIDENT 
LIMIT.—One-third of such number 
shall be available for distribution only 
to hospitals described in subparagraph 
(B). 
‘‘(II) AGGREGATE LIMITATION.— 
Except as provided in clause (iv)(I), 
the aggregate number of increases in 
the otherwise applicable resident limit 
under this subparagraph shall be 
equal to 3,000 in each such year. 
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‘‘(iii) PROCESS
FOR
DISTRIBUTING 
POSITIONS.— 
‘‘(I) 
ROUNDS
OF
APPLICA-
TIONS.—The Secretary shall initiate 5 
separate rounds of applications for an 
increase under clause (i), 1 round 
with respect to each of fiscal years 
2013 through 2017. 
‘‘(II) NUMBER
AVAILABLE.—In 
each of such rounds, the aggregate 
number of positions available for dis-
tribution in the fiscal year under 
clause (ii) shall be distributed, plus 
any 
additional 
positions 
available 
under clause (iv). 
‘‘(III) TIMING.—The Secretary 
shall notify hospitals of the number of 
positions distributed to the hospital 
under this paragraph as a result of an 
increase in the otherwise applicable 
resident limit by January 1 of the fis-
cal year of the increase. Such increase 
shall be effective for portions of cost 
reporting periods beginning on or 
after July 1 of that fiscal year. 
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the considerations and priority de-
scribed in subparagraph (C), conduct 
an application and distribution proc-
ess in each subsequent fiscal year 
until such time as the aggregate 
amount of positions distributed under 
this paragraph is equal to 15,000. 
‘‘(B) ALLOCATION OF DISTRIBUTION FOR 
POSITIONS TO HOSPITALS ALREADY OPERATING 
OVER RESIDENT LIMIT.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), in the case of a hospital in 
which the reference resident level of the 
hospital (as specified in subparagraph 
(G)(iii)) is greater than the otherwise ap-
plicable resident limit, the increase in the 
otherwise applicable resident limit under 
subparagraph (A) for a fiscal year de-
scribed in such subparagraph shall be an 
amount equal to the product of the total 
number of additional residency positions 
available for distribution under subpara-
graph (A)(ii)(I) for such fiscal year and 
the quotient of— 
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‘‘(I) the number of resident posi-
tions by which the reference resident 
level of the hospital exceeds the other-
wise applicable resident limit for the 
hospital; and 
‘‘(II) the number of resident po-
sitions by which the reference resident 
level of all such hospitals with respect 
to which an application is approved 
under this paragraph exceeds the oth-
erwise applicable resident limit for 
such hospitals. 
‘‘(ii) REQUIREMENTS.—A hospital de-
scribed in clause (i)— 
‘‘(I) is not eligible for an increase 
in the otherwise applicable resident 
limit under this subparagraph unless 
the amount by which the reference 
resident level of the hospital exceeds 
the otherwise applicable resident limit 
is not less than 10 and the hospital 
trains at least 25 percent of the full- 
time equivalent residents of the hos-
pital in primary care and general sur-
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gery (as of the date of enactment of 
this paragraph); and 
‘‘(II) shall continue to train at 
least 25 percent of the full-time equiv-
alent residents of the hospital in pri-
mary care and general surgery for the 
5-year period beginning on such date. 
In the case where the Secretary determines 
that a hospital described in clause (i) no 
longer meets the requirement of subclause 
(II), the Secretary may reduce the other-
wise applicable resident limit of the hos-
pital by the amount by which such limit 
was increased under this subparagraph. 
‘‘(iii) CLARIFICATION REGARDING ELI-
GIBILITY
FOR
OTHER
ADDITIONAL
RESI-
DENCY POSITIONS.—Nothing in this sub-
paragraph shall be construed as preventing 
a hospital described in clause (i) from ap-
plying for and receiving additional resi-
dency positions under this paragraph that 
are not reserved for distribution under this 
subparagraph. 
‘‘(C) DISTRIBUTION
OF
OTHER
POSI-
TIONS.—For purposes of determining an in-
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crease in the otherwise applicable resident limit 
under subparagraph (A) (other than such an in-
crease described in subparagraph (B)), the fol-
lowing shall apply: 
‘‘(i) CONSIDERATIONS
IN
DISTRIBU-
TION.—In determining for which hospitals 
such an increase is provided under sub-
paragraph (A), the Secretary shall take 
into account the demonstrated likelihood of 
the hospital filling the positions made 
available under this paragraph within the 
first 5 cost reporting periods beginning 
after the date the increase would be effec-
tive, as determined by the Secretary. 
‘‘(ii) PRIORITY
FOR
CERTAIN
HOS-
PITALS.—Subject to clause (iii), in deter-
mining for which hospitals such an in-
crease is provided, the Secretary shall dis-
tribute the increase in the following pri-
ority order: 
‘‘(I) First, to hospitals in States 
with (aa) new medical schools that re-
ceived ‘Candidate School’ status from 
the Liaison Committee on Medical 
Education or that received ‘Pre-Ac-
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creditation’ status from the American 
Osteopathic Association Commission 
on Osteopathic College Accreditation 
on or after January 1, 2000, and that 
have achieved or continue to progress 
toward ‘Full Accreditation’ status (as 
such term is defined by the Liaison 
Committee on Medical Education) or 
toward ‘Accreditation’ status (as such 
term is defined by the American Os-
teopathic Association Commission on 
Osteopathic College Accreditation), or 
(bb) additional locations and branch 
campuses established on or after Jan-
uary 1, 2000, by medical schools with 
‘Full Accreditation’ status (as such 
term is defined by the Liaison Com-
mittee on Medical Education) or ‘Ac-
creditation’ status (as such term is 
defined by the American Osteopathic 
Association Commission on Osteo-
pathic College Accreditation). 
‘‘(II) Second, to hospitals that 
emphasize 
training 
in 
community 
health center or community-based set-
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tings or in hospital outpatient depart-
ments. 
‘‘(III) Third, to hospitals that 
are eligible for incentive payments 
under section 1886(n) or 1903(t) as 
of the date the hospital submits an 
application for such increase under 
subparagraph (A). 
‘‘(IV) Fourth, to all other hos-
pitals. 
‘‘(iii) DISTRIBUTION TO HOSPITALS IN 
HIGHER PRIORITY GROUP PRIOR TO DIS-
TRIBUTION IN LOWER PRIORITY GROUPS.— 
The Secretary may only distribute such an 
increase to a lower priority group under 
clause (ii) if all qualifying hospitals in the 
higher priority group or groups have re-
ceived the maximum number of increases 
under such subparagraph that the hospital 
is eligible for under this paragraph for the 
fiscal year. 
‘‘(iv) REQUIREMENTS FOR USE OF AD-
DITIONAL POSITIONS.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), a hospital that receives 
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such an increase shall ensure, during 
the 5-year period beginning on the ef-
fective date of such increase, that— 
‘‘(aa) not less than 50 per-
cent of the positions attributable 
to such increase that are used in 
a given year during such 5-year 
period are used to train full-time 
equivalent residents in a shortage 
specialty residency program (as 
defined in subparagraph (G)(v)), 
as determined by the Secretary 
at the end of such 5-year period; 
‘‘(bb) the total number of 
full-time equivalent residents, ex-
cluding any additional positions 
attributable to such increase, is 
not less than the average number 
of full-time equivalent residents 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease; and 
‘‘(cc) the ratio of full-time 
equivalent residents in a shortage 
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specialty residency program (as 
so defined) is not less than the 
average ratio of full-time equiva-
lent residents in such a program 
during the 3 most recent cost re-
porting periods ending on or be-
fore the effective date of such in-
crease. 
‘‘(II) REDISTRIBUTION OF POSI-
TIONS
IF
HOSPITAL
NO
LONGER 
MEETS
CERTAIN
REQUIREMENTS.— 
With respect to each fiscal year de-
scribed in subparagraph (A), the Sec-
retary shall determine whether or not 
a hospital described in subclause (I) 
meets the requirements of such sub-
clause. In the case that the Secretary 
determines that such a hospital does 
not meet such requirements, the Sec-
retary shall— 
‘‘(aa) reduce the otherwise 
applicable resident limit of the 
hospital by the amount by which 
such limit was increased under 
this paragraph; and 
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‘‘(bb) provide for the dis-
tribution of positions attributable 
to such reduction in accordance 
with the requirements of this 
paragraph. 
‘‘(D) LIMITATION.—A hospital may not re-
ceive more than 75 full-time equivalent addi-
tional residency positions under this paragraph 
for any fiscal year. 
‘‘(E) APPLICATION
OF
PER
RESIDENT 
AMOUNTS
FOR
PRIMARY
CARE
AND
NONPRI-
MARY CARE.—With respect to additional resi-
dency positions in a hospital attributable to the 
increase provided under this paragraph, the ap-
proved FTE per resident amounts are deemed 
to be equal to the hospital per resident amounts 
for primary care and nonprimary care com-
puted under paragraph (2)(D) for that hospital. 
‘‘(F) PERMITTING
FACILITIES
TO
APPLY 
AGGREGATION
RULES.—The Secretary shall 
permit hospitals receiving additional residency 
positions attributable to the increase provided 
under this paragraph to, beginning in the fifth 
year after the effective date of such increase, 
apply such positions to the limitation amount 
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under paragraph (4)(F) that may be aggre-
gated pursuant to paragraph (4)(H) among 
members of the same affiliated group. 
‘‘(G) DEFINITIONS.—In this paragraph: 
‘‘(i) OTHERWISE
APPLICABLE
RESI-
DENT LIMIT.—The term ‘otherwise appli-
cable resident limit’ means, with respect to 
a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graphs (7)(A), (7)(B), (8)(A), and (8)(B). 
‘‘(ii) PRIMARY CARE.—The term ‘pri-
mary care’ means family medicine, general 
internal medicine, general pediatrics, pre-
ventive medicine, obstetrics and gyne-
cology, general surgery, and psychiatry. 
‘‘(iii) 
REFERENCE
RESIDENT 
LEVEL.—Except as otherwise provided in 
subclause (II), the term ‘reference resident 
level’ means, with respect to a hospital, the 
resident level for the most recent cost re-
porting period of the hospital ending on or 
before the date of enactment of this para-
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graph, for which a cost report has been 
settled (or, if not, submitted (subject to 
audit)), as determined by the Secretary. 
‘‘(iv) RESIDENT
LEVEL.—The term 
‘resident level’ has the meaning given such 
term in paragraph (7)(C)(i). 
‘‘(v) 
SHORTAGE
SPECIALTY
RESI-
DENCY
PROGRAM.—The term ‘shortage 
specialty residency program’ means the fol-
lowing: 
‘‘(I) 
PRIOR
TO
REPORT
ON 
SHORTAGE
SPECIALTIES.—Prior 
to 
the date on which the report is sub-
mitted under section 5 of the Resident 
Physician Shortage Reduction and 
Graduate Medical Education Account-
ability and Transparency Act, any ap-
proved residency training program in 
a specialty identified in the report en-
titled ‘The Physician Workforce: Pro-
jections and Research into Current 
Issues Affecting Supply and Demand’, 
issued in December 2008 by the 
Health Resources and Services Ad-
ministration, as a specialty whose 
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baseline physician requirements pro-
jections exceed the projected supply of 
total active physicians for the period 
of 2005 through 2020. 
‘‘(II) AFTER REPORT ON SHORT-
AGE SPECIALITIES.—On or after the 
date on which the report is submitted 
under such section 5, any approved 
residency training program in a physi-
cian specialty identified in such report 
as a specialty for which there is a 
shortage.’’. 
(b) IME.—Section 1886(d)(5)(B) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 
(1) in clause (v), in the second sentence, by 
striking ‘‘subsections (h)(7) and (h)(8)’’ and insert-
ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 
(2) by redesignating clause (x), as added by 
section 5505(b) of the Patient Protection and Af-
fordable Care Act (Public Law 111–148), as clause 
(xi) and moving such clause 4 ems to the left; and 
(3) by adding after clause (xi), as redesignated 
by subparagraph (A), the following new clause: 
‘‘(xii) For discharges occurring on or after July 
1, 2013, insofar as an additional payment amount 
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under this subparagraph is attributable to resident 
positions distributed to a hospital under subsection 
(h)(9), the indirect teaching adjustment factor shall 
be computed in the same manner as provided under 
clause (ii) with respect to such resident positions.’’. 
SEC. 3. MEDICARE INDIRECT MEDICAL EDUCATION PER-
FORMANCE ADJUSTMENT. 
Section 1886 of the Social Security Act (42 U.S.C. 
1395ww) is amended— 
(1) in subsection (d)(5)(B), in the matter pre-
ceding clause (i), by inserting ‘‘subject to subsection 
(t) and’’ before ‘‘except as follows’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(t) INDIRECT MEDICAL EDUCATION PERFORMANCE 
ADJUSTMENTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, the Secretary shall es-
tablish and implement procedures under which the 
amount of payments that a hospital (as defined in 
paragraph (11)) would otherwise receive for indirect 
medical education costs under subsection (d)(5)(B) 
for discharges occurring during a fiscal year is ad-
justed based on the reporting of measures and the 
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performance of the hospital on measures of patient 
care priorities specified by the Secretary. 
‘‘(2) ADJUSTMENTS TO BEGIN IN FISCAL YEAR 
2017.—The adjustments shall apply to payments for 
discharges occurring— 
‘‘(A) with respect to the adjustments for 
reporting under paragraph (8)(A), during fiscal 
year 2017; and 
‘‘(B) with respect to the adjustments for 
performance under paragraph (8)(B), on or 
after October 1, 2017. 
‘‘(3) MEASURES.—The measures of patient care 
priorities specified by the Secretary under this sub-
section shall include the extent of training provided 
in— 
‘‘(A) the delivery of services categorized as 
evaluation and management codes by the Cen-
ters for Medicare & Medicaid Services; 
‘‘(B) a variety of settings and systems; 
‘‘(C) the coordination of patient care 
across settings; 
‘‘(D) the relevant cost and value of various 
diagnostic and treatment options; 
‘‘(E) 
interprofessional 
and 
multidisci-
plinary care teams; 
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‘‘(F) methods for identifying system errors 
and implementing system solutions; and 
‘‘(G) the use of health information tech-
nology. 
‘‘(4) MEASURE DEVELOPMENT PROCESS.— 
‘‘(A) IN GENERAL.—The measures of pa-
tient care specified by the Secretary under this 
subsection— 
‘‘(i) shall— 
‘‘(I) be measures that have been 
adopted or endorsed by an accrediting 
organization (such as the Accredita-
tion Council for Graduate Medical 
Education or American Osteopathic 
Association); and 
‘‘(II) be measures that the Sec-
retary identifies as having used a con-
sensus-based process for developing 
such measures; and 
‘‘(ii) may include measures that have 
been submitted by teaching hospitals and 
medical schools. 
‘‘(B) PROPOSED
SET
OF
INITIAL
MEAS-
URES.—Not later than July 1, 2014, the Sec-
retary shall publish in the Federal Register a 
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proposed initial set of measures for use under 
this subsection. The Secretary shall provide for 
a period of public comment on such measures. 
‘‘(C) FINAL SET OF INITIAL MEASURES.— 
Not later than January 1, 2015, the Secretary 
shall publish in the Federal Register the set of 
initial measures to be specified by the Secretary 
for use under this subsection. 
‘‘(D) UPDATE
OF
MEASURES.—The Sec-
retary may, through notice and comment rule-
making, periodically update the measures speci-
fied under this subsection pursuant to the re-
quirements under subparagraph (A). 
‘‘(5) PERFORMANCE
STANDARDS.—The Sec-
retary shall establish performance standards with re-
spect to measures specified by the Secretary under 
this subsection for a performance period for a fiscal 
year (as established under paragraph (6)). 
‘‘(6) PERFORMANCE
PERIOD.—The Secretary 
shall establish the performance period for a fiscal 
year. Such performance period shall begin and end 
prior to the beginning of such fiscal year. 
‘‘(7) REPORTING
OF
MEASURES.—The proce-
dures established and implemented under paragraph 
(1) shall include a process under which hospitals 
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shall submit data on the measures specified by the 
Secretary under this subsection to the Secretary in 
a form and manner, and at a time, specified by the 
Secretary for purposes of this subsection. 
‘‘(8) ADJUSTMENTS.— 
‘‘(A) REPORTING FOR FISCAL YEAR 2017.— 
For fiscal year 2017, in the case of a hospital 
that does not submit, to the Secretary in ac-
cordance with this subsection, data required to 
be submitted under paragraph (7) for a period 
(determined appropriate by the Secretary) for 
such fiscal year, the total amount that the hos-
pital would otherwise receive under subsection 
(d)(5)(B) for discharges in such fiscal year 
shall be reduced by 0.5 percent. 
‘‘(B) PERFORMANCE
FOR
FISCAL
YEAR 
2018 AND SUBSEQUENT FISCAL YEARS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), based on the performance of each hos-
pital with respect to compliance with the 
measures for a performance period for a 
fiscal year (beginning with fiscal year 
2018), the Secretary shall determine the 
amount of any adjustment under this sub-
paragraph to payments to the hospital 
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under subsection (d)(5)(B) for discharges 
in such fiscal year. Such adjustment may 
not exceed an amount equal to 2 percent 
of the total amount that the hospital would 
otherwise receive under such subsection for 
discharges in such fiscal year. 
‘‘(ii) BUDGET NEUTRAL.—In making 
adjustments under this subparagraph, the 
Secretary shall ensure that the total 
amount of payments made to all hospitals 
under subsection (d)(5)(B) for discharges 
in a fiscal year is equal to the total amount 
of payments that would have been made to 
such hospitals under such subsection for 
discharges in such fiscal year if this sub-
section had not been enacted. 
‘‘(9) NO
EFFECT
IN
SUBSEQUENT
FISCAL 
YEARS.—Any adjustment under subparagraph (A) 
or (B) of paragraph (8) shall apply only with respect 
to the fiscal year involved, and the Secretary shall 
not take into account any such adjustment in mak-
ing payments to a hospital under this section in a 
subsequent fiscal year. 
‘‘(10) EVALUATION
OF
SUBMISSION
OF
PER-
FORMANCE MEASURES.—Not later than January 1, 
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2017, the Secretary shall submit to Congress a re-
port on the implementation of this subsection, in-
cluding— 
‘‘(A) the measure development procedures, 
including any barriers to measure development; 
‘‘(B) the compliance with reporting on the 
performance measures, including any barriers 
to such compliance; and 
‘‘(C) recommendations to address any bar-
riers described in subparagraph (A) or (B). 
‘‘(11) DEFINITION OF HOSPITAL.—In this sub-
section, the term ‘hospital’ means a hospital that re-
ceives payments under subsection (d)(5)(B).’’. 
SEC. 4. INCREASING GRADUATE MEDICAL EDUCATION 
TRANSPARENCY. 
(a) IN GENERAL.—Not later than 2 years after the 
date of the enactment of this Act, and annually thereafter, 
the Secretary of Health and Human Services shall submit 
to Congress and the National Health Care Workforce 
Commission a report on the graduate medical education 
payments that hospitals receive under the Medicare pro-
gram. The report shall include the following information 
with respect to each hospital that receives such payments: 
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(1) The direct graduate medical education pay-
ments made to the hospital under section 1886(h) of 
the Social Security Act (42 U.S.C. 1395ww(h)). 
(2) The total costs of direct graduate medical 
education to the hospital as reported on the annual 
Medicare Cost Reports. 
(3) The indirect medical education payments 
made to the hospital under section 1886(d)(5)(B) of 
such Act (42 U.S.C. 1395ww(d)(1)(B)). 
(4) The number of full-time-equivalent residents 
counted for purposes of making the payments de-
scribed in paragraph (1). 
(5) The number of full-time-equivalent residents 
counted for purposes of making the payments de-
scribed in paragraph (3). 
(6) The number of full-time-equivalent resi-
dents, if any, that are not counted for purposes of 
making payments described in paragraph (1). 
(7) The number of full-time-equivalent resi-
dents, if any, that are not counted for purposes of 
making payments described in paragraph (3). 
(8) The factors contributing to the higher costs 
of patient care provided by the hospital, including— 
(A) the costs of trauma, burn, other stand-
by services; 
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(B) translation services for disabled or 
non-English speaking patients; 
(C) the cost of uncompensated care; 
(D) financial losses with respect to Med-
icaid patients; and 
(E) uncompensated costs of clinical re-
search. 
SEC. 5. GAO STUDY AND REPORT ON PHYSICIAN WORK-
FORCE. 
(a) STUDY.—The Comptroller General of the United 
States shall conduct a study on the physician workforce. 
Such study shall include the identification of physician 
specialties for which there is a shortage, as defined by the 
Comptroller General. 
(b) REPORT.—Not later than January 1, 2014, the 
Comptroller General shall submit to Congress a report on 
the study conducted under subsection (a), together with 
recommendations for such legislation and administrative 
action as the Comptroller General determines appropriate. 
SEC. 6. STUDY AND REPORT ON STRATEGIES FOR INCREAS-
ING DIVERSITY. 
(a) STUDY.—The Comptroller General of the United 
States shall conduct a study on strategies for increasing 
the diversity of the health professional workforce. Such 
study shall include an analysis of strategies for increasing 
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the number of health professionals from rural, lower in-
come, and under-represented minority communities, in-
cluding which strategies are most effective for achieving 
such goal. 
(b) REPORT.—Not later than 2 years after the date 
of enactment of this Act, the Comptroller General shall 
submit to Congress a report on the study conducted under 
subsection (a), together with recommendations for such 
legislation and administrative action as the Comptroller 
General determines appropriate. 
Æ 
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