I
106TH CONGRESS
1ST SESSION
H. R. 3000
To establish a United States Health Service to provide high quality com-
prehensive health care for all Americans and to overcome the deficiencies
in the present system of health care delivery.
IN THE HOUSE OF REPRESENTATIVES
OCTOBER 1, 1999
Ms. LEE (for herself, Mrs. CHRISTENSEN, and Mr. JACKSON of Illinois) intro-
duced the following bill; which was referred to the Committee on Com-
merce, and in addition to the Committees on Education and the Work-
force, and Ways and Means, for a period to be subsequently determined
by the Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
A BILL
To establish a United States Health Service to provide high
quality comprehensive health care for all Americans and
to overcome the deficiencies in the present system of
health care delivery.
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
‘‘Josephine Butler United States Health Service Act’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Purposes.
Sec. 4. Definitions.
TITLE I—ESTABLISHMENT AND OPERATION OF THE UNITED
STATES HEALTH SERVICE
Subtitle A—Initial Organization
Sec. 101. Establishment of the Service.
Sec. 102. Appointment of Interim National Health Board.
Sec. 103. Powers and duties of the Interim National Health Board.
Sec. 104. Authorization.
Subtitle B—Organization of Area Health Boards
Sec. 111. Establishment of health care delivery regions.
Sec. 112. Appointment of interim regional health boards.
Sec. 113. Establishment of health care delivery districts and health care deliv-
ery communities.
Sec. 114. Election of community health boards.
Sec. 115. Appointment of district health boards.
Sec. 116. Appointment of regional health boards.
Sec. 117. Appointment of the National Health Board.
Sec. 118. Subsequent election and appointment of members of health boards.
Sec. 119. Modification of the boundaries of health care delivery areas.
Subtitle C—General Provisions Regarding Health Boards
Sec. 121. Definitions.
Sec. 122. Membership of health boards.
Sec. 123. Meetings and records of health boards.
Sec. 124. Procedures for establishment of national guidelines and standards.
Sec. 125. Assistance to area health board members.
Sec. 126. Public accountability and financial disclosure by health board mem-
bers.
Sec. 127. Inspector General for Health Services.
TITLE II—DELIVERY OF HEALTH CARE AND SUPPLEMENTAL
SERVICES
Subtitle A—Patients’ Rights in Health Care Delivery
Sec. 201. Basic health rights.
Sec. 202. Right to paid leave to receive health care services.
Subtitle B—Eligibility for, Nature of, and Scope of Services Provided by the
Service
Sec. 211. Eligibility for services.
Sec. 212. Entitlement to services.
Sec. 213. Provision of health care and supplemental services.
Subtitle C—Health Care Facilities and Delivery of Health Care Services
Sec. 221. Establishment of health care facilities and distribution of delivery of
health care and other services.
Sec. 222. Operation and inspection of health care facilities.
Sec. 223. Provision of health services relating to reproduction and childbearing.
TITLE III—HEALTH LABOR FORCE
Subtitle A—Job Categories and Certification
Sec. 301. Effect of State law.
Sec. 302. Qualifications of health workers.
Sec. 303. Establishment of job categories and certification standards.
Subtitle B—Education of Health Workers
Sec. 311. Health team schools.
Sec. 312. Service requirement.
Sec. 313. Payment for certain educational loans.
Subtitle C—Employment and Labor-Management Relations Within the Service
Sec. 321. Employment, transfer, promotion, and receipt of fees.
Sec. 322. Applicability of laws relating to Federal employees.
Sec. 323. Applicability of Federal labor-management relations laws.
Sec. 324. Defense of certain malpractice and negligence suits.
TITLE IV—OTHER FUNCTIONS OF HEALTH BOARDS
Subtitle A—Advocacy, Grievance Procedures, and Trusteeships
Sec. 401. Advocacy and legal services program.
Sec. 402. Grievance procedures and trusteeships.
Subtitle B—Occupational Safety and Health Programs
Sec. 411. Functions of the National Health Board.
Sec. 412. Community occupational safety and health activities.
Sec. 413. Regional occupational safety and health programs.
Sec. 414. Workplace health facilities.
Sec. 415. Employee rights relating to occupational safety and health.
Sec. 416. Definitions.
Subtitle C—Health and Health Care Delivery Research, Quality Assurance,
and Health Equity
Sec. 421. Principles and guidelines for research.
Sec. 422. Establishment of institutes.
Subtitle D—Health Planning, Distribution of Drugs and Other Medical
Supplies, and Miscellaneous Functions
Sec. 431. Health planning and budgeting.
Sec. 432. Distribution of drugs and other medical supplies.
Sec. 433. Miscellaneous functions of the National Health Board.
TITLE V—FINANCING OF THE SERVICE
Subtitle A—Health Service Taxes
Sec. 501. Individual and corporate income taxes.
Sec. 502. Other changes in the Internal Revenue Code of 1986.
Sec. 503. Existing employer-employee health benefit plans.
Sec. 504. Workers compensation programs.
Subtitle B—Health Service Trust Fund
Sec. 511. Establishment of health service trust fund.
Sec. 512. Transfer of funds to the health service trust fund.
Sec. 513. Administration of health service trust fund.
Subtitle C—Preparation of Plans and Budgets
Sec. 521. Determination of fund availability.
Sec. 522. Preparation of area plans and budgets.
Subtitle D—Allocation and Distribution of Funds
Sec. 531. National budget.
Sec. 532. Regional budgets.
Sec. 533. District budgets.
Sec. 534. Special operating expense fund.
Sec. 535. Distribution of funds.
Sec. 536. Annual statement, records, and audits.
Subtitle E—General Provisions
Sec. 541. Issuance of obligations.
Sec. 542. Definitions.
TITLE VI—MISCELLANEOUS PROVISIONS
Sec. 601. Effective date of health services.
Sec. 602. Repeal of provisions.
Sec. 603. Transition provisions.
Sec. 604. Amendment to Budget and Accounting Act.
Sec. 605. Separability.
SEC. 2. FINDINGS.
The Congress makes the following findings:
(1) The health of the Nation’s people is a foun-
dation of their well-being.
(2) High quality health care is a right of all
people.
(3) Many of the Nation’s people are unable
fully to exercise this right because of the inability of
the present health care delivery system to make high
quality health care available to all individuals re-
gardless of race, sex, age, national origin, income,
marital status, sexual orientation, religion, political
belief, place of residence, employment status, or pre-
vious health status.
(4) The present health care system has failed to
provide financial coverage for health care services
for more than forty million Americans, and the per-
cent lacking such coverage grows each year.
(5) The present health care system has failed to
provide for sufficient effective preventive measures
that would address the deterioration in occupational,
environmental, and social conditions affecting the
health of the people of this Nation.
(6) Unnecessary and excessive profits and ad-
ministrative expenses have inflated the cost of health
care.
(7) The growth of for-profit medical care and
for-profit managed care is making it difficult for
health care personnel to provide, and users to re-
ceive, the full range of health services they believe to
be necessary, appropriate, and desirable.
(8) The health professions have failed to control
the cost of their services and the imbalance in the
number of health workers among geographic areas
or health care specialties.
(9) The present health care system has failed to
make full and efficient use of allied health workers.
(10) A United States Health Service is the best
means to implement the right to high quality health
care and to overcome the deficiencies in the present
health care delivery system.
SEC. 3. PURPOSES.
The purposes of this Act are:
(1) To create a United States Health Service to
provide without charge to all residents, regardless of
race, sex, age, national origin, income, marital sta-
tus, sexual orientation, religion, political belief, place
of residence, employment status, or previous health
status, comprehensive health care services delivered
by salaried health workers and emphasizing the pro-
motion and maintenance of health as well as the
treatment of illness.
(2) To establish representative and democratic
governance of the Service through community boards
chosen through community elections, district and re-
gional boards selected by the community and district
boards, respectively, and a National Health Board
selected by the regional boards, subject to the ap-
proval of the President.
(3) To provide health workers in the Service
with fair and reasonable compensation, secure em-
ployment, opportunities for full and equal participa-
tion in the governance of health facilities, and oppor-
tunities for advancement without regard to race, sex,
age, national origin, sexual orientation, religion, or
political belief.
(4) To increase the availability and continuity
of health care by linking local health care facilities
to hospitals and specialized care facilities.
(5) To implement local, regional, and national
planning for the establishing, equipping, and staffing
of health care facilities needed to overcome present
shortages and redistribute health resources, espe-
cially for currently deprived inner-city and rural pop-
ulations, minority groups, prisoners, and occupa-
tional groups.
(6) To finance the Service through progressive
taxation of individuals and employer contributions,
and to distribute these revenues on a capitation
basis, supplemented by allocations to meet special
health care needs.
SEC. 4. DEFINITIONS.
For the purposes of this Act, unless the context im-
plies otherwise:
(1) SERVICE.—The term ‘‘Service’’ means the
United States Health Service established in section
101.
(2) 
NATIONAL
HEALTH
BOARD-RELATED
TERMS.—
(A) NATIONAL HEALTH BOARD.—The term
‘‘National Health Board’’ means the National
Health Board of the Service.
(B) INTERIM NATIONAL HEALTH BOARD.—
The term ‘‘Interim National Health Board’’
means the Interim National Health Board, ap-
pointed under section 102, of the Service.
(C) 
APPROPRIATE
NATIONAL
HEALTH
BOARD.—The 
term 
‘‘appropriate 
National
Health Board’’ means—
(i) 
the 
Interim 
National 
Health
Board, prior to the initial meeting of the
National Health Board under section 117,
and
(ii) the National Health Board, at and
after such meeting.
(3) HEALTH BOARD-RELATED TERMS.—
(A) HEALTH BOARD.—The term ‘‘health
board’’ means the Interim National Health
Board, National Health Board, an interim re-
gional health board, a regional health board, a
district health board, or a community health
board established under this Act.
(B) AREA
HEALTH
BOARD.—The term
‘‘area health board’’ means a regional health
board, a district health board, or a community
health board established under this Act.
(4) AREA-RELATED TERMS.—
(A) COMMUNITY.—The term ‘‘community’’
means a health care delivery community estab-
lished under title I.
(B) 
DISTRICT.—The 
term 
‘‘district’’
means a health care delivery district established
under title I.
(C) REGION.—The term ‘‘region’’ means a
health care delivery region established under
title I.
(D) AREA.—The term ‘‘area’’ means, with
respect to an area health board or an area
health care facility—
(i) in the case of a community board
or a health care facility established by a
community board, the community for
which such board is established or in which
the facility is located;
(ii) in the case of a district board or
a health care facility established by a dis-
trict board, the district for which such
board is established or in which the facility
is located; and
(iii) in the case of a regional board or
a health care facility established by a re-
gional board, the region for which such
board is established or in which the facility
is located.
(5) LOCAL BOARD-RELATED TERMS.—
(A) 
INTERIM
REGIONAL
BOARD.—The
term ‘‘interim regional board’’ means an in-
terim regional health board established in ac-
cordance with section 112.
(B) REGIONAL
BOARD.—The term ‘‘re-
gional board’’ means a regional health board es-
tablished in accordance with title I.
(C) DISTRICT BOARD.—The term ‘‘district
board’’ means a district health board estab-
lished in accordance with title I.
(D) COMMUNITY BOARD.—The term ‘‘com-
munity board’’ means a community health
board established in accordance with title I.
(6) REGIONAL AND DISTRICT BOARDS.—
(A) RESPECTIVE REGIONAL BOARD.—The
terms ‘‘respective regional board’’ and ‘‘respec-
tive interim regional board’’ mean, with respect
to a community board or a district board, the
regional board or interim regional board, re-
spectively, for the region which contains the
community or district for which such commu-
nity board or district board is established.
(B) RESPECTIVE
DISTRICT
BOARD.—The
term ‘‘respective district board’’ means, with re-
spect to a community board, the district board
for the district which contains the community
for which such community board is established.
(7) USER-RELATED TERMS.—
(A) USER.—The term ‘‘user’’ means an in-
dividual who is eligible under section 211 to re-
ceive health care services from the Service
under this Act.
(B) REGISTERED USER.—The term ‘‘reg-
istered user’’ means, with respect to an area, a
user who resides in the area and is registered
to vote in the area in general elections for Fed-
eral, State, or local officials.
(C) ELIGIBLE USER.—The term ‘‘eligible
user’’ means, for purposes of sections 114
through 118, with respect to a community, dis-
trict, or region, an individual who (i) is 18
years of age or older, (ii) resides in the commu-
nity, district, or region, respectively, and (iii) is
not a health worker (as defined in paragraph
(8)(A)), an indirect provider of health care (as
defined in subparagraph (E)), or a member of
the immediate family of such a worker or indi-
rect provider.
(D) USER
MEMBER.—The term ‘‘user
member’’ means, with respect to a health board,
an eligible user elected or appointed by users or
user members to the health board under sec-
tions 114 through 118.
(E) INDIRECT
PROVIDER
OF
HEALTH
CARE.—The term ‘‘indirect provider of health
care’’ means an individual who—
(i) receives (either directly or through
his or her spouse) more than one-tenth of
his or her gross annual income from any
one or combination of—
(I) fees or other compensation
for provision of, research into, or in-
struction in, the provision of health
care,
(II) entities engaged in the provi-
sion of health care or in such research
or instruction,
(III) 
producing 
or 
supplying
drugs, medical equipment, or other ar-
ticles for individuals or entities for use
in the provision of or in research into
or instruction in the provision of
health care, or
(IV) entities engaged in pro-
ducing drugs, medical equipment, or
such other articles;
(ii) holds a fiduciary position with, or
has a fiduciary interest in, any entity de-
scribed in subclause (II) or (IV) of clause
(i); or
(iii) is engaged in issuing any policy
or contract of individual or group health
insurance or hospital or medical service
benefits.
(8) WORKER-RELATED TERMS.—
(A) HEALTH WORKER.—The term ‘‘health
worker’’ includes—
(i) any employee of the Service; and
(ii) any individual who for remunera-
tion delivers, administers any program in,
provides supporting services for, teaches
the subject matter of, or performs research
in, health care services.
(B) AUTHORIZED HEALTH WORKER.—The
term ‘‘authorized health worker’’ means, with
respect to a specified health care service, an in-
dividual who is an employee of the Service and
is authorized by a health board to deliver the
service.
(C) ELIGIBLE AREA HEALTH WORKER.—
The term ‘‘eligible area health worker’’ means,
for purposes of sections 114 through 118 with
respect to a community, district, or region, a
health worker who is employed by the commu-
nity, district, or regional health board (respec-
tively) or, in the case of sections 114 through
117, is scheduled to be employed by such board
on the effective date of health services.
(D) WORKER MEMBER.—The term ‘‘work-
er member’’ means, with respect to a health
board, an eligible area health worker elected or
appointed by health workers or worker members
to the health board under sections 114 through
118.
(9) FACILITY-RELATED TERMS.—
(A) HEALTH CARE FACILITY.—The term
‘‘health care facility’’ means an administrative
unit composed of specified staff, equipment,
and premises and established by a health board
as an appropriate unit of organization for the
delivery of specified health care or supplemental
services under this Act.
(B) AREA HEALTH CARE FACILITY.—The
term ‘‘area health care facility’’ means, with re-
spect to an area health board, a health care fa-
cility established by the area health board.
(10) SERVICE-RELATED TERMS.—
(A) HEALTH CARE SERVICES.—The term
‘‘health care services’’ means the services de-
scribed in paragraphs (1) through (5) of section
213(a).
(B) SUPPLEMENTAL SERVICES.—The term
‘‘supplemental services’’ means the services de-
scribed in paragraphs (1), (2), and (3) of sec-
tion 213(b).
(11) NUMBER
OF
RESIDENTS.—The term
‘‘number of residents’’ means the number of resi-
dents in a health care delivery area as determined by
the most recent decennial national census.
(12) EFFECTIVE
DATE
OF
HEALTH
SERV-
ICES.—The term ‘‘effective date of health services’’
means the effective date of health services under this
Act as specified in section 601.
TITLE I—ESTABLISHMENT AND
OPERATION OF THE UNITED
STATES HEALTH SERVICE
Subtitle A—Initial Organization
SEC. 101. ESTABLISHMENT OF THE SERVICE.
(a) IN GENERAL.—There is established, as an inde-
pendent establishment of the executive branch of the
United States, the United States Health Service.
(b) AUTHORITY.—
(1) NATIONAL HEALTH BOARD.—The authority
of the Service shall be exercised by the appropriate
National Health Board and, in accordance with this
Act and guidelines established by such Board, by
area health boards.
(2) EMINENT DOMAIN AUTHORITY.—The Serv-
ice shall have the authority, under the power of emi-
nent domain, to acquire by condemnation under ju-
dicial process real estate for the Service for public
purposes whenever it is necessary or advantageous
to do so.
SEC. 102. APPOINTMENT OF INTERIM NATIONAL HEALTH
BOARD.
(a) IN GENERAL.—The President shall, no later than
30 days after the date of the enactment of this Act, ap-
point 21 individuals—
(1) who are 18 years of age or older;
(2) who are concerned about the health care
problems of the Nation;
(3) who approximate the Nation’s population by
race, sex, income, language, and region of residence,
and approximate the percentage of rural and fron-
tier populations; and
(4) no more than seven of whom are or have
been health workers, indirect providers of health
care, or members of the immediate family of such
workers or indirect providers within 24 months of
the date of such nomination.
To serve as members of the Interim National Health
Board of the Service.
(b) DESIGNATION
OF
CHAIRPERSON
AND
VICE
CHAIRPERSON.—The President shall, at the time of such
appointments, designate two nominees to the Interim Na-
tional Health Board who are not and have not been health
workers, indirect providers of health care, or members of
the immediate family of such workers or indirect providers
within 24 months of the date of such appointment as
chairperson and vice chairperson of such Board.
SEC. 103. POWERS AND DUTIES OF THE INTERIM NATIONAL
HEALTH BOARD.
(a) TERM.—The members of the Interim National
Health Board shall serve as the National Health Board
of the Service until the National Health Board holds its
initial meeting in accordance with section 117(c)(2).
(b) DUTIES.—The Interim National Health Board
shall—
(1) establish the boundaries of health care de-
livery regions, in accordance with section 111;
(2) select interim regional health boards in ac-
cordance with section 111;
(3) assist interim regional health boards in the
performance of their functions;
(4) coordinate the initial election of community
health boards, under section 114; and
(5) carry out such duties of the National
Health Board as it deems necessary and consistent
with the timetable given under this Act and the pur-
poses of the Service, except that no staff member
may be appointed and no employee may be hired by
the Interim National Health Board for a period ex-
tending beyond 90 days after the appointment of the
National Health Board under section 117.
(c) APPLICATION OF REQUIREMENTS.—The Interim
National Health Board shall operate in a manner con-
sistent with the provisions of subtitle C.
(d) INITIAL REPORT.—The Interim National Health
Board shall submit a report to Congress on its perform-
ance under this Act no later than 30 days after the ap-
pointment of the National Health Board under section
117.
SEC. 104. AUTHORIZATION.
There are authorized to be appropriated to the Serv-
ice $4,000,000,000 to carry out the provisions of this Act
with respect to the establishment of the Service. Funds
appropriated under this section shall remain available
until expended.
Subtitle B—Organization of Area
Health Boards
SEC. 111. ESTABLISHMENT OF HEALTH CARE DELIVERY RE-
GIONS.
(a) ESTABLISHMENT OF HEALTH CARE DELIVERY
REGIONS.—No later than 6 months after the appointment
of members of the Interim National Health Board, such
Board shall establish, in accordance with this section,
health care delivery regions throughout the United States.
(b) REQUIREMENTS FOR DELIVERY REGIONS.—Each
health care delivery region shall meet the following re-
quirements:
(1) The region shall be a contiguous geographic
area appropriate for the effective governance, plan-
ning, and delivery of all health care and supple-
mental services under this Act for residents of the
region.
(2) The region shall have a population of not
less than 500,000 and of not more than 3,000,000
individuals, except that—
(A) the population of a region may be
more than 3,000,000 if the region includes a
standard metropolitan statistical area (as deter-
mined by the Office of Management and Budg-
et) with a population of more than three mil-
lion; and
(B) the population of a region may be less
than 500,000 if the Interim National Health
Board determines that this is necessary to fa-
cilitate the delivery of health care and supple-
mental services or the effective governance of
the health program within such region.
A region under subparagraph (B) may be a sparsely
populated frontier area which consists of a very
large or multi-state geographic area.
(3) The boundaries of each region shall take
into account—
(A) any economic or geographic barrier to
the receipt of health care and supplemental
services in nonmetropolitan areas, and
(B) the differences in needs between non-
metropolitan and metropolitan areas in the
planning, development, and delivery of health
care and supplemental services.
(c) PROCESS.—At least 60 days prior to the estab-
lishment of the boundaries of any region, the Interim Na-
tional Health Board shall provide for—
(1) notice in the area which would be affected
by the establishment of such boundaries of the
boundaries proposed to be established, and of the
date, time, and location of the public hearing on
such establishment as provided in paragraph (2);
and
(2) a public hearing at which individuals can
speak or present written statements relating to the
establishment of such boundaries.
(d) MODIFICATION OF BOUNDARIES.—The bound-
aries of regions shall be modified in accordance with sec-
tion 119.
SEC. 112. APPOINTMENT OF INTERIM REGIONAL HEALTH
BOARDS.
(a) 
APPOINTMENT
OF
INTERIM
REGIONAL
BOARDS.—No later than 60 days after the establishment
of health care delivery regions under section 111, the In-
terim National Health Board shall appoint an interim re-
gional board for each such region.
(b) COMPOSITION.—Each interim regional board
shall be composed of nine members—
(1) who are 18 years of age or older;
(2) who are concerned about the health care
problems of their region;
(3) who approximate the region’s population by
race, sex, income, and language; and
(4) no more than three of whom are or have
been health workers, indirect providers or health
care, or members of the immediate family of such
workers or indirect providers within 24 months of
the date of such appointment.
(c) DESIGNATION
OF
CHAIRPERSON
AND
VICE
CHAIRPERSON.—The Interim National Health Board
shall, at the time of appointment of each interim regional
board, designate two members of the board who are not
and have not been health workers, indirect providers of
health care, or members of the immediate family of such
workers or indirect providers within 24 months of the date
of such appointment as chairperson and vice chairperson
of such board.
(d) VACANCIES.—A vacancy in the membership of an
interim regional board shall be filled in the same manner
as the original appointment.
(e) TERM.—The members of an interim regional
board shall serve until the certification of appointment of
a regional board in its region in accordance with section
116.
(f) DUTIES.—Each interim regional board shall—
(1) establish the boundaries of health care de-
livery districts and of health care delivery commu-
nities within its region in accordance with section
113;
(2) conduct elections for voting members of
community boards within its region, in accordance
with section 114; and
(3) carry out such functions of a regional
board, set out under this Act, as the Interim Na-
tional Health Board deems appropriate for the pur-
poses of this Act.
(g) OPERATIONAL REQUIREMENTS.—Each interim
regional board shall operate in a manner in accordance
with subtitle C of this title.
SEC. 113. ESTABLISHMENT OF HEALTH CARE DELIVERY
DISTRICTS AND HEALTH CARE DELIVERY
COMMUNITIES.
(a) IN GENERAL.—No later than 6 months after its
appointment under section 112, each interim regional
board shall establish, in accordance with this section,
health care delivery districts and health care delivery com-
munities throughout its region.
(b) DIVISION INTO DISTRICTS.—Each region shall be
divided into three or more health care delivery districts.
Each such district shall meet the following requirements:
(1) The district shall be a contiguous geo-
graphic area appropriate for the effective govern-
ance, planning, and delivery of all health care serv-
ices, except for highly specialized health services, for
residents of such district.
(2) The district shall have a population of not
less than 100,000 and of not more than 500,000 in-
dividuals, except that a district may have a popu-
lation of less than 100,000 if the interim regional
board or regional board (as appropriate) determines
that a lesser population would facilitate the delivery
of health care and supplemental services or the ef-
fective governance of the health program within such
district or its region.
(c) DIVISION OF DISTRICTS INTO COMMUNITIES.—
Each district shall be divided into three or more health
care delivery communities. Each such community shall
meet the following requirements:
(1) The community shall be a contiguous geo-
graphic area appropriate for the effective govern-
ance, planning, and delivery of comprehensive pri-
mary health care services, described in section
221(a)(2), for residents of such community.
(2) The residents of the community shall, to the
maximum extent feasible, have a commonality of in-
terest, language, and ethnic and racial composition
sufficient to support and maintain a community
health program under this Act.
(3) The community shall have a population of
not less than 25,000 and of not more than 50,000
individuals, except in the case of Indian reservations
and, except that a community may have a population
of less than 25,000 if the interim regional board or
regional board (as appropriate) determines that a
lesser population would facilitate the delivery of
health care and supplemental services or the effec-
tive governance of the health program within such
community or the district in which it is located.
(d) PROCESS.—At least 60 days prior to the estab-
lishment of the boundaries of any district or community
within its region, the interim regional board shall provide
for—
(1) notice in the district or community which
would be affected by the establishment of such
boundaries of the boundaries proposed to be estab-
lished and of the date, time, and location of the pub-
lic hearing on such establishment as provided in
paragraph (2); and
(2) a public hearing at which individuals resid-
ing within the region can speak or present written
statements relating to the establishment of such
boundaries.
(e) PROCESS FOR MODIFICATION OF BOUNDARIES.—
The boundaries of districts and communities shall be
modified in accordance with section 119.
SEC. 114. ELECTION OF COMMUNITY HEALTH BOARDS.
(a) IN GENERAL.—
(1) USER
MEMBERS.—The Interim National
Health Board shall arrange with State and local
governments for the initial elections for user mem-
bers of each community board to be held on a date
not later than 9 months after the appointment of in-
terim regional boards under section 112.
(2) WORKER MEMBERS.—Elections for worker
members of each community board shall first be held
as soon as possible after the selection of health
workers for employment by the user members of
such community boards. Such elections shall be held,
to the extent feasible, in accordance with subsection
(c)(2)(B).
(b) NUMBER.—
(1) USER
MEMBERS.—The number of user
members to be elected in an election in a community
under subsection (a) shall be six, plus one user
member for each 5,000 individuals residing in such
community in excess of 30,000 residents.
(2) WORKER MEMBERS.—The number of work-
er members to be elected in an election in a commu-
nity under subsection (a) shall be three, plus one
member for each 10,000 individuals residing in such
community in excess of 30,000 residents.
(c) NOMINATION AND ELECTION PROCEDURES.—
(1) 
IN
GENERAL.—The 
Interim 
National
Health Board shall establish procedures for the
nomination and election under this section of user
members of community boards and worker members
of area health boards. Each interim regional board
shall conduct and supervise such nominations and
elections in its region in accordance with such proce-
dures.
(2) NOMINATION PROCESS.—
(A) USER MEMBERS.—Such procedures for
election of user members shall provide, except
as otherwise provided in this subtitle, for—
(i) the nomination for election as a
user member to a community board of any
eligible user, upon presentation to the re-
spective interim regional board of a peti-
tion or petitions signed by at least one per-
cent of the registered users in the commu-
nity;
(ii) the full disclosure by each nomi-
nee, at the time of presentation of a peti-
tion or petitions under clause (i), to the re-
spective interim regional board of any fi-
nancial interest of the nominee and such
nominee’s family in the delivery of health
care services, in research on health or
health care services, or in the provision of
drugs or medical supplies;
(iii) the opportunity, regardless of
race, sex, language, income level, or health
condition, for all registered users in each
such community to nominate eligible users
for, and for all eligible users in each such
community to run for and to serve as user
members of, such users’ community board;
(iv) the right of all registered users in
each such community, regardless of race,
sex, language, income level, or health con-
dition, to vote in elections for user mem-
bers of such users’ community board, and
the right of registered users who are not
physically or mentally capable of voting
themselves to designate other registered
users to vote proxies on their behalf;
(v) public meetings sponsored by the
respective interim regional board in each
such community within its region, at which
all users nominated for election to the
community board in the community may
present their views;
(vi) the preparation and distribution
within each such community by the respec-
tive interim regional board of literature
presenting the qualifications and views of,
and disclosing information described in
clause (ii) for, each nominee for election as
a user member of the community board in
the community; and
(vii) the election of the nominees re-
ceiving the greatest number of votes.
(B) WORKER MEMBERS.—Such procedures
for election of worker members shall provide
for—
(i) the nomination for election as a
worker member of an area health board of
any eligible area health worker, upon pres-
entation to the respective interim regional
board of a petition (or petitions) signed by
at least 1 percent of the eligible area
health workers, and
(ii) the full participation of eligible
area health workers of all job categories
and skill levels in the nomination and elec-
tion process.
(d) CERTIFICATION.—
(1) IN
GENERAL.—Unless an election is set
aside under section 402(d)(1) (relating to grievance
procedures), individuals who have been elected to a
community board for a community under this sec-
tion, including user members until worker members
have been elected, shall be certified by the interim
regional board as constituting, on the date of such
certification, the community board for the commu-
nity.
(2) INITIAL MEETING.—With respect to each
group of individuals constituting a community board
under paragraph (1), the respective interim regional
board shall select a time, date, and location within
the community of such community board for the
holding of the initial meeting of such community
board, which date shall not be later than 30 days
after the date of the election, and shall notify the
newly elected and approved members of such board
and the residents of such community of the time,
date, and location of such meeting.
SEC. 115. APPOINTMENT OF DISTRICT HEALTH BOARDS.
(a) INITIAL APPOINTMENT.—
(1) USER MEMBERS.—Not later than 60 days
after the initial meeting of each community board,
called pursuant to section 114(d)(2), the user mem-
bers of each such board shall appoint two eligible
users in the community to serve as user members of
their respective district board.
(2) WORKER MEMBERS.—As soon as feasible,
the worker members of each such board shall ap-
point an eligible community health worker to serve
as a worker member of their respective district
board.
(3) WORKER MEMBERS.—As soon as feasible,
the eligible district health workers shall, in accord-
ance with section 114(c)(2)(B), elect an eligible dis-
trict health worker to serve as a worker member of
their respective district board.
(4) NOTICE OF APPOINTMENT.—The user and
worker members of each such community board shall
promptly notify their respective interim regional
board of appointments under this subsection.
(b) CERTIFICATION.—
(1) IN GENERAL.—Not later than 15 days after
the date a majority of the initial community boards
within a district have notified their respective in-
terim regional board of the appointment of user
members for their respective district boards under
subsection (a)(1), such interim regional board shall
certify the users so appointed as constituting, on the
date of such certification, the district board for the
district.
(2) INITIAL MEETING.—With respect to each
district board certified under paragraph (1), its re-
spective interim regional board shall select a time,
date, and location within the district of such district
board for the holding of the initial meeting of such
district board, which date shall not be later than 15
days after the date of such certification, and shall
notify the approved members of such board and the
residents of such district of the time, date, and loca-
tion of such meeting.
SEC. 116. APPOINTMENT OF REGIONAL HEALTH BOARDS.
(a) IN GENERAL.—
(1) USER MEMBERS.—Not later than 60 days
after the initial meeting of each district board, called
pursuant to section 115(b)(2), the user members of
each such board shall appoint two eligible users in
the district to serve as user members of their respec-
tive regional board.
(2) APPOINTMENT OF WORKER MEMBER.—As
soon as feasible, the worker members of each such
board shall appoint an eligible district (or commu-
nity, in the district) health worker to serve as a
worker member of their respective regional board.
(3) ELECTION OF WORKER MEMBER.—As soon
as feasible, the eligible regional health workers shall,
in accordance with section 114(c)(2)(B), elect an eli-
gible regional health worker to serve as a worker
member of their respective regional board.
(4) NOTICE.—The user and worker members of
each such district board shall promptly notify their
respective interim regional board and the Interim
National Health Board of such appointments.
(b) CERTIFICATION.—
(1) IN GENERAL.—Not later than 15 days after
the date a majority of the initial certified district
boards within a region have notified their respective
interim regional board of the appointment of user
members for their respective regional board under
subsection (a)(1), such interim regional board shall
certify the users so appointed as constituting, on the
date of such certification, the regional board for the
region.
(2) INITIAL MEETING.—With respect to each
regional board certified under paragraph (1), the in-
terim regional board that certified such board shall
select a time, date, and location within its region for
the holding of the initial meeting of such regional
board, which date shall not be later than 15 days
after the date of such certification, and shall notify
the appointed and approved members of such board
and the residents of its region of the time, date, and
location of such meeting.
SEC. 117. APPOINTMENT OF THE NATIONAL HEALTH
BOARD.
(a) ASSIGNMENT OF REGIONS.—The Interim Na-
tional Health Board shall, for purposes of appointing
members of the National Health Board, assign each region
to one of three groups of regions, each group having (to
the extent possible) an equal number and balanced geo-
graphic distribution of regions.
(b) APPOINTMENT OF MEMBERS.—
(1) USER MEMBER.—Not later than 60 days
after the initial meeting of each regional board,
called pursuant to section 116(b)(2), each such
board for a region in the first two groups of regions
(established under subsection (a)) shall appoint
(subject to the approval of the President) an eligible
user in the region to serve as a user member of the
National Health Board.
(2) WORKER
MEMBER.—As soon as feasible,
each such board for any other region shall appoint
(subject to approval of the President) an eligible re-
gional (or community or district, in the region)
health worker to serve as a worker member of the
National Health Board.
(3) NOTICE AND REVIEW.—Each regional board
shall promptly notify the Interim National Health
Board and the President of each appointment under
this subsection. The President shall approve or dis-
approve the appointment of such a member within
the 10-day period beginning on the date of his noti-
fication of the appointment; and the appointment of
such a member shall be considered as having been
approved by the President unless he disapproves the
appointment of the member within such time period.
(c) CERTIFICATION.—
(1) IN GENERAL.—No later than 15 days after
the date a majority of the appointments under sub-
section (b)(1) by initially certified regional boards
have been approved by the President, the Interim
National Health Board shall certify the individuals
so approved as constituting, on the date of such cer-
tification, the National Health Board, and shall
promptly notify the President and the Congress of
such certification.
(2) INITIAL MEETING.—The Interim National
Health Board shall select a time, date, and location
for the holding of the initial meeting of the National
Health Board, which date shall not be later than 15
days after the date of the certification under para-
graph (1), and shall notify appointed and approved
members and the public of the time, date, and loca-
tion of such meeting.
SEC. 118. SUBSEQUENT ELECTION AND APPOINTMENT OF
MEMBERS OF HEALTH BOARDS.
(a) TERMS.—Members of health boards elected or ap-
pointed in accordance with sections 114 through 117 shall
serve until their successors are certified in accordance with
this section.
(b) ELECTIONS.—
(1) USER
MEMBERS.—The National Health
Board shall arrange with State and local govern-
ments for an election for user members of each com-
munity board to be held on the date of, and in con-
junction with, each election for Members of the
United States House of Representatives that occurs
after the effective date of health services.
(2) WORKER MEMBERS.—An election for work-
er members of each community board shall be held
on or about the date of each election specified in
paragraph (1) and shall be held, to the extent fea-
sible and consistent with section 114(c)(2)(B), in
conjunction with the election under paragraph (1).
(3) PROCESS.—The provisions of section 114
(other than subsection (a) thereof) shall apply to
elections of members of community boards under
this subsection, except that for purposes of this
subsection—
(A) the term of each member elected under
this subsection shall be 4 years, except that, in
the case of the elections first held under this
section, the term of half of the user members
and of half of the worker members or, in the
case of an odd number of user or worker mem-
bers, the term of half plus one of such members
shall be 2 years;
(B) the individuals whose term of office
does not expire following an election, as well as
individuals elected in the election, are deemed
to constitute the community board under sec-
tion 114(d)(1); and
(C) any reference to an interim regional
board or to the Interim National Health Board
in section 114 shall be considered as a reference
to a regional board or to the National Health
Board.
(c) COMMUNITIES.—
(1) ASSIGNMENT.—Each regional board shall,
for purposes of appointing worker members of dis-
trict boards within its region, assign each commu-
nity to one of two groups of communities within
each district, each group having (to the extent pos-
sible) an equal number and balanced geographic dis-
tribution of communities.
(2) APPOINTMENT.—Not later than 60 days
after the initial meeting of each community board
(newly certified after an election under subsection
(b))—
(A) in the case of the first new certifi-
cation of such a board—
(i) user members of each such board
shall appoint two eligible users in the com-
munity, one of whom shall serve a 4-year
term as a user member of their respective
district board and the other a 2-year term
on such board; and
(ii) worker members of each such
board for a community in the first group
of communities (established under para-
graph (1)) shall appoint an eligible com-
munity health worker to serve a 4-year
term as a worker member of their respec-
tive district board, and worker members of
each such board for a community in the
second group of communities shall appoint
an eligible community health worker to
serve a 2-year term on such board;
(B) in the case of a subsequent new certifi-
cation of such a board—
(i) user members of each such board
shall appoint an eligible user for a 4-year
term; and
(ii) worker members of each such
board for a community in a group of com-
munities that did not appoint a worker
member to serve a 4-year term after the
previous certification shall appoint an eligi-
ble community health worker to serve a 4-
year term; and
(C) beginning with the first new certifi-
cation of such a board, and every 4 years there-
after, the eligible district health workers shall,
in accordance with section 114(c)(2)(B), elect
an eligible district health worker to serve a 4-
year term as a worker member of their respec-
tive district board.
The user and worker members of each such commu-
nity board shall promptly notify their respective re-
gional board of such appointments.
(3) CERTIFICATION.—Not later than 15 days
after the date a majority of the newly certified com-
munity boards within a district have notified their
respective regional board of the appointment or elec-
tion of individuals for their respective district boards
under paragraph (2), such regional board shall cer-
tify the users and workers whose term of office does
not expire at the time of such appointments or elec-
tions, as well as individuals newly appointed or elect-
ed, as constituting, on the date of such certification,
the district board for the district.
(4) INITIAL MEETING.—For each district board
certified under paragraph (3), the respective regional
board shall select a time, date, and location within
the district of such district board for the holding of
the initial meeting of such new board, which date
shall be not later than 15 days after the date of
such certification, and shall notify the members of
such board appointed under this subsection and the
residents of the district of the time, date, and loca-
tion of such meeting.
(d) DISTRICTS.—
(1) ASSIGNMENT.—The National Health Board
shall, for purposes of appointing worker members of
regional boards, assign each district to one of two
groups of districts within each region, each group
having (to the extent possible) an equal number and
balanced geographic distribution of districts.
(2) APPOINTMENT.—Not later than 60 days
after the initial meeting of each newly certified dis-
trict board (held pursuant to subsection (c)(4))—
(A) in the case of the first new certifi-
cation of such a board—
(i) user members of each such board
shall appoint two eligible users in the dis-
trict, one of whom shall serve a 4-year
term as a user member of their respective
regional board and the other a 2-year term
on such board; and
(ii) worker members of each such
board for a district in the first group of
districts (established under paragraph (1))
shall appoint an eligible district (or com-
munity, within the district) health worker
to serve a 4-year term as a worker member
of their respective regional board, and
worker members of each such board for a
district in the second group of districts
shall appoint an eligible district (or com-
munity, within the district) health worker
to serve a 2-year term on such board;
(B) in the case of a subsequent new certifi-
cation of such a board—
(i) user members of each such board shall
appoint an eligible user for a 4-year term; and
(ii) worker members of each such
board for a district in a group of districts
that did not appoint a worker member to
serve a 4-year term after the previous cer-
tification shall appoint an eligible district
(or community, within the district) health
worker to serve a 4-year term; and
(C) beginning with the first new certifi-
cation of such a board, and every 4 years there-
after, the eligible regional health workers shall,
in accordance with section 114(c)(2)(B), elect
an eligible regional healthworker to serve a 4-
year term as a worker member of their respec-
tive regional board.
The user and worker members of each such district
board shall promptly notify the National Health
Board of such appointments.
(3) CERTIFICATION.—Not later than 15 days
after the date a majority of the newly certified dis-
trict boards within a region have notified the Na-
tional Health Board of the appointment or election
of individuals for their respective regional boards
under paragraph (2), the National Health Board
shall certify the users and workers whose term of of-
fice does not expire at the time of such appoint-
ments or elections, as well as individuals newly ap-
pointed or elected, as constituting, on the date of
such certification, the regional board for the region.
(4) INITIAL
MEETING.—For each regional
board newly certified under paragraph (3), the pre-
viously certified regional board shall select a time,
date, and location within the region for the holding
of the initial meeting of such new board, which date
shall not be later than 15 days after the date of
such certification, and shall notify the members of
such board appointed and approved under this sub-
section and the residents of the region of the time,
date, and location of such meeting.
(e) NATIONAL HEALTH BOARD.—
(1) APPOINTMENTS.—Not later than 60 days
after the initial meeting of each newly certified re-
gional board, held pursuant to subsection (d)(4)—
(A) in the case of the first new certifi-
cation of such a board—
(i) each such board for a region in the
first group of regions (established under
section 117(a)) shall appoint (subject to
the approval of the President) an eligible
regional (or community or district, in the
region) health worker, and
(ii) each such board for any other re-
gion shall appoint (subject to the approval
of the President) an eligible user in the re-
gion,
to serve a 4-year term as a member of the Na-
tional Health Board; and
(B) in the case of a subsequent new certifi-
cation of such a board occurring when the
terms of office of members of the National
Health Board are expiring—
(i) each such board for a region in a
group of regions that has appointed an eli-
gible user to serve as a member of the Na-
tional Board for the previous two appoint-
ments under this subsection or section
117(b) shall appoint (subject to the ap-
proval of the President) an eligible regional
(or community or district, in the region)
health worker, and
(ii) each such board for any other re-
gion shall appoint (subject to the approval
of the President) an eligible user in the re-
gion,
to serve a 4-year term as a member of the Na-
tional Health Board.
Each such board shall promptly notify the National
Health Board and the President of such appoint-
ment. The President shall approve or disapprove the
appointment of such a member within the 10-day
period beginning on the date of his notification of
the appointment; and the appointment of such a
member shall be considered as having been approved
by the President unless he disapproves the appoint-
ment of the member within such time period.
(2) CERTIFICATION.—No later than 15 days
after the date a majority of the appointments under
paragraph (1) by newly certified regional boards
have been approved by the President, the National
Health Board shall certify the individuals so ap-
proved as constituting, on the date of such certifi-
cation, the National Health Board and shall prompt-
ly notify the President and Congress of such certifi-
cation.
(3) INITIAL MEETING.—The previously certified
National Health Board shall select a time, date, and
location for the holding of the initial meeting of the
new National Health Board, which date shall not be
later than 15 days after the date of certification of
such Board under paragraph (2), and shall notify
the members appointed and approved under this
subsection and the public of the time, date, and loca-
tion of such meeting.
SEC. 119. MODIFICATION OF THE BOUNDARIES OF HEALTH
CARE DELIVERY AREAS.
(a) IN GENERAL.—No later than 2 years after each
decennial national census, and at such other times as it
deems necessary, the National Health Board shall review
the appropriateness of the boundaries of each health care
delivery region and may, in accordance with subsection
(b), modify the boundary of any region in which there has
been a substantial shift of population justifying such modi-
fication, if such modification is approved in a referendum
of registered users residing in an area whose regional iden-
tification would be changed by making such modification.
(b) PROCESS.—At least 60 days before the modifica-
tion by referendum of the boundary of any region, the Na-
tional Health Board shall provide for—
(1) notice in the area whose regional identifica-
tion would be changed by the modification of such
boundaries—
(A) of existing boundaries and of the pro-
posed modification, and
(B) of the date, time, and location of the
public hearing on such modification, as required
in paragraph (2), and
(2) a public hearing at which individuals can
speak or present written statements relating to the
modification of such boundaries.
(c) REVIEW OF APPROPRIATENESS.—
(1) IN GENERAL.—After the establishment of
regional health boards under section 116—
(A) no later than 2 years after each decen-
nial national census,
(B) upon receipt of a petition for modifica-
tion of a boundary of a district or community
within the region of such board, which petition
is signed by not less than 15 percent (or 10
percent, in the case of a region where more
than one-third of the geographic area includes
frontier communities, of the residents residing
in the frontier portion of the region) of the reg-
istered users residing in an area whose district
or community identification would be changed
by adoption of such petition, and
(C) at such other times as it deems appro-
priate,
each regional board shall review the appropriateness
of the boundaries of districts and communities with-
in its region.
(2) PROCESS.—Any review conducted under
paragraph (1) shall comply with the procedures of
subsection (d) (relating to open hearings and public
participation).
(3) STANDARDS
FOR
MODIFICATION.—A re-
gional board, after reviewing the boundaries of a dis-
trict or community within its region under para-
graph (1), may modify the boundary of any such
district or community if—
(A) there has been a substantial shift of
population justifying such modification, or
(B) such modification would better carry
out the purposes of this Act, and
if such modification is approved in a referendum,
held after notice and a public hearing in accordance
with subsection (d), of registered users residing in
an area whose district or community identification
would be changed by adoption of the proposed modi-
fication.
(d) PROCESS.—At least 60 days before the modifica-
tion by referendum of the boundary of any district or com-
munity, the respective regional board shall provide for—
(1) notice in the area whose district or commu-
nity identification would be changed by the modifica-
tion of such boundaries—
(A) of existing boundaries and of the
boundaries proposed to be modified, and
(B) of the date, time, and location of the
public hearing on such modification, as required
in paragraph (2), and
(2) a public hearing at which individuals can
speak or present written statements relating to the
modification of such boundaries.
Subtitle C—General Provisions
Regarding Health Boards
SEC. 121. DEFINITIONS.
As used in this subtitle, the term ‘‘full member’’
means, with respect to a health board, a member of such
board other than an associate member described in section
122(a)(4).
SEC. 122. MEMBERSHIP OF HEALTH BOARDS.
(a) COMPOSITION.—Each health board shall be com-
posed of—
(1) members elected or appointed and approved
in accordance with this subtitle B;
(2) one member—
(A) in the case of a community board, ap-
pointed by the occupational safety and health
action council established under section 412 for
such community, and
(B) in the case of a regional board, ap-
pointed by the occupational safety and health
action council established under section 413 for
such region;
(3) such voting user members as the members
of the board described in paragraphs (1) and (2)
may determine from time to time (in consultation
with elements of the population from which the
members are being selected) to be necessary in order
to ensure that (A) the user members of the board
approximate the population within its area by race,
sex, income level, and language and (B) segments of
the population having special health needs (such as
the physically and mentally handicapped and the
aged) are appropriately represented; and
(4) such nonvoting associate members as the
members of such board may determine from time to
time to be necessary to provide appropriate rep-
resentation of appropriate units of State, territorial,
and local government and of segments of the popu-
lation having special health needs; and in the case
of the Interim National Health Board and National
Health Board, to carry out the purposes of this Act.
(b) TERM LIMITS.—
(1) IN GENERAL.—Except as provided in para-
graph (2), no individual may serve as a full member
of a health board in a community, district, or region,
or of the National Health Board, for more than four
consecutive years, exclusive of any time that might
be served as a member by election or appointment
(A) before the effective date of health services, (B)
for a 2-year term under section 118(b)(3)(A),
118(c)(2)(A), or 118(d)(2)(A), or (C) by appoint-
ment under subsection (d) to fill a vacancy.
(2) EXCEPTION.—Full members of a health
board shall serve until their successors are certified
in accordance with this Act.
(c) .—
(1) RECALL ELECTIONS.—
(A) IN GENERAL.—Within 60 days of the
date of the presentation to the appropriate re-
gional board of a petition, signed by at least 15
percent of the number of registered users resid-
ing in a community or of eligible area health
workers, requesting the recall of a user member
or elected worker member, respectively, of a
board elected and approved in accordance with
this title, such regional board shall conduct an
election on the recall of such member.
(B) PROCESS.—The provisions of section
114 (except for subsection (a) thereof) and pro-
cedures established thereunder regarding elec-
tions of user and worker members shall apply
with respect to recall elections conducted under
this paragraph, except that for the purposes of
this paragraph, any reference in such section to
an interim regional board or to the Interim Na-
tional Health Board shall be considered as a
reference to a regional board or to the National
Health Board, respectively.
(2) VOTE REQUIRED.—A member of a district
or regional board or an interim regional board ap-
pointed in accordance with this title may be recalled
from office by the affirmative vote of two-thirds of
the members of the health board which appointed
such member.
(3) REMOVAL
OF
NATIONAL
HEALTH
BOARD
MEMBER.—A member of the Interim National
Health Board or National Health Board may be re-
moved from office by the President for neglect of
duty, malfeasance in office, or, in the case of the
National Health Board, upon recommendation by
the affirmative vote of two-thirds of the members of
the regional board which nominated such member.
(d) VACANCIES.—
(1) IN
GENERAL.—A vacancy caused by the
death, resignation, or removal of a member (in this
subsection referred to as a ‘‘vacating member’’) of a
health board, elected or appointed in accordance
with this title, before the expiration of the term for
which such vacating member was elected or ap-
pointed, shall be filled not later than 60 days after
the date of such vacancy—
(A) in the case of a member of a commu-
nity board, by election of an eligible individual,
in accordance with section 114 (except for sub-
section (a) thereof);
(B) in the case of a member of a district
or regional board, an interim regional board, or
the National Health Board, by appointment or
election and, in the case of the National Health
Board, Presidential approval of an eligible indi-
vidual by the health board or workers which ap-
pointed or elected such vacating member; and
(C) in the case of a member of the Interim
National Health Board, by appointment by the
President.
(2) TERM
OF
VACANCY
APPOINTMENT.—Any
individual appointed to fill a vacancy under this sub-
section shall serve only for the unexpired term of of-
fice of the vacating member.
(3) ELIGIBLE INDIVIDUAL DEFINED.—For the
purposes of this subsection, the term ‘‘eligible indi-
vidual’’ means, with respect to filling the place of a
vacating member, an individual who is eligible,
under the applicable provisions of this Act, to serve
on a health board in the capacity in which the
vacating member was elected or appointed.
SEC. 123. MEETINGS AND RECORDS OF HEALTH BOARDS.
(a) FULL MEMBER RIGHTS.—
(1) VOTING.—Each full member of a health
board shall have one vote in meetings of such board.
(2) QUORUM.—A majority of the full members
of each health board shall constitute a quorum for
the transaction of the business of such board, and
such board shall act upon the vote of a majority of
the full members present and voting.
(b) CHAIRPERSON.—
(1) ELECTION.—Except as otherwise provided
in this Act, the full members of each health board
shall, at the first meeting following the certification
of such board, elect a chairperson and vice chair-
person from among the full members of such board.
(2) RESPONSIBILITIES.—The chairperson of
each health board shall be responsible for convening
meetings of such board and for such other duties as
such board may assign. Upon the written request of
two full members of such board, the chairperson
shall convene a meeting of such board.
(3) VICE CHAIRPERSON.—The vice chairperson
shall perform the duties of the chairperson in the
event that the chairperson is unable to perform such
functions.
(c) RECORDS.—
(1) IN GENERAL.—Each health board shall pro-
vide for the recording of the minutes of each of its
meetings and each of the meetings of its committees
and advisory groups, and shall make such records
available to the public for inspection and copying.
(2) ACCESS.—Meetings of each health board
and each committee and advisory group thereof (ex-
cept meetings that concern an individual user or
health worker, and such individual requests that the
meeting be closed) shall be open to the public and
shall be held at such times and in such places as
the board determines to be convenient to attendance
by the public.
(3) OFFICE.—Each health board shall establish
a principal office within the area it serves.
(d) DISSEMINATION OF INFORMATION.—Each health
board shall disseminate within the area it serves full infor-
mation regarding its activities, including the furnishing of
health care and supplemental services.
(e) RULES.—
(1) IN GENERAL.—Each health board may es-
tablish such rules, consistent with this Act, as it
finds necessary for the effective and expeditious
transaction of its duties and functions.
(2) COMMITTEES.—Each health board may es-
tablish such committees and advisory groups, and
appoint to them such individuals (including health
workers), as it deems necessary to carry out its du-
ties and functions.
(f) COMPENSATION.—
(1) NATIONAL BOARD.—A full member of the
Interim National Health Board or National Health
Board may receive compensation at a rate not to ex-
ceed the daily equivalent of the annual rate of basic
pay in effect for grade GS–18 of the General Sched-
ule for each day (including traveltime) during which
the member is engaged in the actual performance of
such member’s duties plus reimbursement for travel,
subsistence, and other necessary expenses incurred
in the performance of such member’s duties.
(2) OTHER HEALTH BOARDS.—A full member
of a health board, other than the Interim National
Health Board of the National Health Board, may
receive such amounts per diem when engaged in the
actual performance of such member’s duties, or such
annual salary, plus reimbursement for travel, sub-
sistence, and other necessary expenses incurred in
the performance of such member’s duties, as the ap-
propriate National Health Board may establish.
SEC. 124. PROCEDURES FOR ESTABLISHMENT OF NA-
TIONAL GUIDELINES AND STANDARDS.
(a) IN GENERAL.—In addition to guidelines and
standards otherwise required to be established by this Act,
the National Health Board shall establish by regulation
(after notice and opportunity for public comment) such
guidelines and standards as will facilitate the implementa-
tion of the objectives of this Act and as will encourage
innovation and experimentation in the implementation of
these objectives.
(b) REVIEW.—The National Health Board shall sub-
mit, at least 90 days before the date of publishing a pro-
posed guideline or standard under this Act, each such
guideline or standard to regional boards for their review
and comments.
(c) TECHNICAL ASSISTANCE.—The National Health
Board and the regional boards shall establish programs
that provide orientation, education, and technical assist-
ance (including support staff) to members of area health
boards in the use and application of guidelines and stand-
ards established by the National Health Board.
SEC. 125. ASSISTANCE TO AREA HEALTH BOARD MEMBERS.
Each regional board shall provide orientation, edu-
cation, and technical assistance to members of district and
community boards in its region, and the appropriate Na-
tional Health Board shall provide such support to mem-
bers of regional boards, to insure that such members are
prepared to perform their duties as members of such
boards with maximum effectiveness.
SEC. 126. PUBLIC ACCOUNTABILITY AND FINANCIAL DIS-
CLOSURE BY HEALTH BOARD MEMBERS.
(a) PROHIBITION OF CONFLICTS OF INTEREST.—
(1) IN GENERAL.—Individuals with direct or in-
direct conflicts of interest shall not serve on health
boards at any level. Subject to paragraph (2), such
conflicts may consist of ownership of, employment
in, or other financial affiliation with any industry in
a position to profit or otherwise benefit from the ac-
tivities of the health board.
(2) EXCEPTION.—Paragraph (1) shall not
apply to employment as a health worker by the Serv-
ice as specified in this Act.
(b) DISCLOSURE.—Candidates for health boards at
any level shall fully disclose any such potential conflicts
of interest, and if elected shall sever any affiliations that
could result in a conflict. The severing of such ties shall
be documented and reported to the National Health
Board, which shall be accountable for monitoring and en-
forcing the provisions of this section.
SEC. 127. INSPECTOR GENERAL FOR HEALTH SERVICES.
Within the United States Health Service there shall
be an Office of the Inspector General, to be headed by
an Inspector General for Health Services, that shall have
authority to ensure the effective operation of the health
boards pursuant to this Act and to investigate and pursue
any grievances against such boards. The Inspector Gen-
eral shall have the same authority as an Inspector General
has under the Inspector General Act of 1978.
TITLE II—DELIVERY OF HEALTH
CARE 
AND 
SUPPLEMENTAL
SERVICES
Subtitle A—Patients’ Rights in
Health Care Delivery
SEC. 201. BASIC HEALTH RIGHTS.
The Service, in its delivery of health care services to
users, shall ensure that every such individual is given the
following basic health rights:
(1) The right to receive high quality health care
and supplemental services from any facility within
the Service capable of providing such services with-
out charge and without discrimination on account of
race, sex, age, religion, language, income, marital
status, sexual orientation, dress, or previous health
status.
(2) The right to humane, respectful, dignified,
and comforting health care, and to the reduction of
pain and distressful symptoms.
(3) The right to have all medically necessary or
appropriate health services delivered in a convenient
and timely manner. Any decision to deny or post-
pone such necessary or appropriate care shall be
made only on the basis of temporary and reasonable
limitations in the availability of service personnel
and physical facilities. Users shall have the oppor-
tunity for timely and effective appeal of any decision
to deny or postpone care.
(4) The right to choose the health workers who
shall be responsible for, and the health facilities in
which to receive, the individual’s health care serv-
ices.
(5) The right of access to all information, in-
cluding the individual’s health records and the med-
ical dictionary produced under section 433(b), which
promotes an understanding of health.
(6) The right to have all health care informa-
tion, reports, and educational materials translated
into the individual’s primary language.
(7) The right to receive, prior to the delivery of
any health care service, a careful, prompt, and intel-
ligible—
(A) explanation of the indications, diag-
noses, benefits, side-effects, and risks involved
in the delivery of such service, and a description
of all medically necessary or appropriate alter-
natives to such service (including no treatment);
(B) answer to any question relating to
such health care service; and
(C) explanation of one’s health rights de-
scribed in this subtitle, and
the right to have such health care service delivered
only with the individual’s prior, voluntary, written
consent.
(8) The right to refuse the initial or continuing
delivery of any health care service whenever such re-
fusal does not directly endanger the public health or,
in accordance with State law, the health of the indi-
vidual if the individual is dangerous to himself or
herself.
(9) The right to have all individually identifi-
able information and documents treated confiden-
tially and not disclosed (except for statistical pur-
poses and for the control of communicable diseases,
drug abuse, and child abuse) without the individual’s
prior, voluntary, and written consent.
(10) The right of access at all times to individ-
uals or groups for counseling, health information,
and assistance on health matters, including access to
user advocates who shall—
(A) assist users in choosing the most ap-
propriate sites from which to receive health
services and the most appropriate health work-
ers from whom to receive such services;
(B) provide counseling and assistance to
users in filing complaints; and
(C) investigate instances of poor quality
services or improper treatment of users and
bring such instances to the attention of the ap-
plicable authority.
(11) The right to be accompanied and visited at
any time by a friend, relative, or independent advo-
cate of the individual’s choosing, and the right to
have routine services, such as feeding, bathing,
dressing, and bedding changes, performed by a
friend or relative, if the individual so chooses.
(12) The right, in the event of terminal illness,
to die with a maximum degree of dignity, to be pro-
vided all necessary symptom relief, to be provided
(and for the individual’s family to be provided) coun-
seling and comfort, and to be allowed (if desired) to
die at home.
(13) The right of access to a complaint and
grievance system and to legal assistance to enforce
these rights.
SEC. 202. RIGHT TO PAID LEAVE TO RECEIVE HEALTH
CARE SERVICES.
(a) AMENDMENT
TO
FAIR
LABOR
STANDARDS
ACT.—The Fair Labor Standards Act of 1938 is amended
by inserting after section 7 (29 U.S.C. 207) the following
new section:
‘‘MINIMUM HEALTH LEAVE COMPENSATION
‘‘SEC. 7A. Each employee of any employer who in any
workweek is engaged in commerce or in the production
of goods for commerce, or is employed in an enterprise
engaged in commerce or in the production of goods for
commerce, shall be entitled to receive from the employer,
for each 35 hours he is employed by the employer (not
counting more than 35 hours in any workweek), com-
pensation for one hour of employment at the regular rate
at which the employee is employed (as that term is used
in section 7 of this Act) for an hour (1) during the period
of 52 weeks beginning with the workweek with which the
entitlement is earned, and (2) during which the employee
is unable to work because of the need for the employee
(or a dependent of that employee) to receive necessary
health care services.’’.
(b) CONFORMING AMENDMENTS.—The Fair Labor
Standards Act of 1938 is further amended—
(1) by striking ‘‘sections 6 and 7’’ in section
3(o) and inserting ‘‘sections 6, 7, and 7A’’;
(2)(A) by striking ‘‘and 7’’ in section 13(a) be-
fore paragraph (1) and inserting ‘‘, 7, and 7A’’;
(B) by striking ‘‘sections 6 and 7’’ in section
13(a)(3) and inserting ‘‘sections 6, 7, and 7A’’;
(C) by inserting ‘‘7A,’’ in subsections (d) and
(f) of section 13 after ‘‘7,’’ each place it appears;
(3) by striking ‘‘6 and 7’’ in section 14(d) and
inserting ‘‘6, 7, and 7A’’;
(4) by striking ‘‘section 6 or section 7’’ in sec-
tion 15(a) and inserting ‘‘section 6, 7, or 7A’’;
(5)(A) by striking ‘‘section 6 or section 7’’ in
section 16(b) and inserting ‘‘section 6, 7, or 7A’’;
(B) by striking ‘‘or their unpaid overtime com-
pensation’’ in section 16(b) and inserting ‘‘their un-
paid overtime compensation, or their unpaid health
leave compensation’’;
(C) by inserting ‘‘or of unpaid health leave com-
pensation’’ in section 16(b) after ‘‘amount of unpaid
overtime compensation’’;
(D) by striking ‘‘section 6 or 7’’ in the first
sentence of section 16(c) and inserting ‘‘section 6, 7,
or 7A’’;
(E) by striking ‘‘unpaid overtime compensa-
tion’’ in the first sentence of section 16(c) and in-
serting ‘‘, unpaid overtime compensation, or unpaid
health leave compensation’’;
(F) by striking ‘‘or overtime compensation’’ in
the second sentence of section 16(c) and inserting ‘‘,
overtime compensation, or health leave compensa-
tion’’;
(G) by striking ‘‘or unpaid overtime compensa-
tion under sections 6 and 7’’ in the third sentence
of section 16(c) and inserting ‘‘, unpaid overtime
compensation, or unpaid health leave compensation
under sections 6, 7, and 7A’’;
(6)(A) by inserting ‘‘or minimum health leave
compensation higher than the minimum health leave
compensation established under this Act’’ in the first
sentence of section 18(a) before ‘‘, and no provi-
sion’’; and
(B) by inserting ‘‘, or justify any employer in
reducing health leave compensation provided by him
which is in excess of the applicable minimum health
leave compensation under this Act’’ before the pe-
riod at the end of the second sentence of section
18(a).
Subtitle B—Eligibility for, Nature
of, and Scope of Services Pro-
vided by the Service
SEC. 211. ELIGIBILITY FOR SERVICES.
(a) IN GENERAL.—All individuals while within the
United States are eligible to receive health care and sup-
plemental services under this Act.
(b) UNITED STATES DEFINED.—For purposes of this
section, the term ‘‘United States’’ includes Indian reserva-
tions, the District of Columbia, the Commonwealth of
Puerto Rico, the Virgin Islands, Guam, Samoa, and the
Northern Mariana Islands.
SEC. 212. ENTITLEMENT TO SERVICES.
(a) IN GENERAL.—Except as provided in subsection
(b), the Service shall, on and after the effective date of
health services, provide users with all health care services
and supplemental services described in section 213 which
the Service determines, in accordance with this title, to
be necessary or appropriate for the promotion and en-
hancement of health, for the prevention of disease, and
for the diagnosis and treatment of, and rehabilitation fol-
lowing, injury, disability, or disease.
(b) EXCLUSION.—Services provided under this Act
shall not include personal comfort or cosmetic services un-
less the area health board providing the services deter-
mines that the services are required for health-related rea-
sons.
SEC. 213. PROVISION OF HEALTH CARE AND SUPPLE-
MENTAL SERVICES.
(a) IN GENERAL.—The Service shall provide in the
United States the following health care services in or
through facilities established by the Service—
(1) the promotion of health and well-being
through health education programs to be carried out
in facilities of the Service as well as in workplaces,
schools, and elsewhere utilizing all appropriate
media, and by assisting other Government agencies
in taking appropriate actions to promote health and
well-being;
(2) the prevention of illness, injury, and death
through education and advocacy addressed to the so-
cial, occupational, and environmental causes of ill-
health; through the provision of appropriate preven-
tive services including social, medical, occupational,
and environmental health services, on both an emer-
gency and sustained basis; through screening and
other early detection programs to identify and ame-
liorate the primary causes of ill-health; and, where
appropriate, through actions taken on an emergency
basis to halt environmental threats to life and
health;
(3) the diagnosis and treatment of illness and
injury, including emergency medical services, com-
prehensive outpatient and inpatient health care serv-
ices, occupational health services, mental health
services, dental care, long-term care, and home
health services;
(4) the rehabilitation of the sick and disabled,
including physical, psychological, occupational, and
other specialized therapies; and
(5) the provision of drugs, therapeutic devices,
appliances, equipment, and other medical supplies
(including eyeglasses, other visual aids, dental aids,
hearing aids, and prosthetic devices) certified effec-
tive in the National Pharmacy and Medical Supply
Formulary (published under section 432(a)) and fur-
nished or prescribed by authorized health workers.
The Service may not provide such health care services in
a region, district, or community other than under the aus-
pices of a regional, district, or community board estab-
lished in accordance with this Act.
(b) SUPPLEMENTAL SERVICES.—The Service shall
provide the following services supplemental to the delivery
of health care services in or through health care facilities
established by the Service—
(1) ambulance and other transportation services
to insure ready and timely access to necessary health
care;
(2) child care services for individuals who, dur-
ing the time they receive outpatient health care serv-
ices from the Service or are working in a health care
facility of the Service, are responsible for a child’s
care; and
(3) homemaking and home health services—
(A) to enable the provision of inpatient
health services at a health care facility of the
Service to an individual who has the sole re-
sponsibility for the care (i) of a child under 15
years of age, or (ii) of a physically or mentally
handicapped individual who requires the care of
another individual, and
(B) for the bedfast or severely handicapped
individual; and
(4) such counseling and social service assistance
as will avoid the unnecessary provision of health care
services.
(c) LOCAL PUBLIC HEALTH SERVICES.—The Service
shall conduct the functions, especially those related to en-
vironmental health and the prevention of illness, currently
performed by the departments of health of the States and
localities, to the extent consistent with Federal, State, and
local law, and shall cooperate with State and local govern-
ments in its conduct of such functions.
(d) EMERGENCY HEALTH CARE SERVICES.—The
Service shall provide, at rates established by the National
Health Board, for reimbursement of the cost of emergency
health care services furnished in facilities not operated by
the Service or by health workers not employed by the Serv-
ice, when an injury or acute illness requires immediate
medical attention under circumstances making it medi-
cally impractical for the ill or injured individual to receive
care in a Service facility or by an employee of the Service.
Subtitle C—Health Care Facilities
and Delivery of Health Care
Services
SEC. 221. ESTABLISHMENT OF HEALTH CARE FACILITIES
AND 
DISTRIBUTION 
OF 
DELIVERY 
OF
HEALTH CARE AND OTHER SERVICES.
(a) COMMUNITY FACILITIES.—
(1) IN
GENERAL.—Each community board
shall, not later than the effective date of health serv-
ices and to the maximum extent feasible, establish
and maintain in its community such health care fa-
cilities as are necessary for the efficient and effective
delivery to individuals residing in its community of
comprehensive primary health care services (defined
in paragraph (2)), specialized health care services
(defined in paragraph (3)), special services (defined
in paragraph (4)) and community-oriented health
measures (defined in paragraph (5)). Such health
care facilities shall be established and maintained in
a manner that, as soon as possible and to the great-
est extent feasible, provides services through a single
comprehensive health center.
(2) COMPREHENSIVE PRIMARY HEALTH CARE
SERVICES DEFINED.—As used in paragraph (1), the
term ‘‘comprehensive primary health care services’’
means those basic outpatient health care services
typically needed for the promotion of health and the
prevention and treatment of common illnesses and
includes the following health care services—
(A) general primary medical and dental
care, including diagnosis and treatment, routine
physical 
examinations, 
laboratory, 
and
radiologic services, and home visits by health
workers, as appropriate;
(B) preventive health services, including at
least immunizations, nutrition counseling and
consultation, and periodic screening and assess-
ment services;
(C) children’s health services, including as-
sessment of growth and development, education
and counseling on childrearing and child devel-
opment, and school and day-care center health
services;
(D) obstetrical and gynecological services,
including family planning and contraceptive
services, pregnancy (prenatal and postnatal)
and abortion counseling and services;
(E) comprehensive geriatric services;
(F) vision and hearing examinations and
provision of eyeglasses and other visual aids
and hearing aids;
(G) 24-hour emergency medical services;
(H) provision of pharmaceuticals and
therapeutic devices, and medical appliances and
equipment;
(I) mental health services, including psy-
chological and psychiatric counseling;
(J) home health services; and
(K) occupational safety and health serv-
ices, including screening, diagnosis, treatment,
and education.
(3) SPECIALIZED HEALTH CARE SERVICES DE-
FINED.—As used in paragraph (1), the term ‘‘spe-
cialized health care services’’ means those health
care services of a specialized nature (whether deliv-
ered in an inpatient or outpatient setting) which, ap-
plying guidelines established by the National Health
Board and by the respective regional board, may be
provided most effectively and efficiently in a commu-
nity setting.
(4) SPECIAL SERVICES DEFINED.—As used in
paragraph (1), the term ‘‘special services’’ means
supportive services and the facilities (including nurs-
ing homes and multiservice centers) in which such
services are provided for individuals who are phys-
ically or mentally handicapped, mentally ill, infirm,
or chronically ill, so as to promote the integration
and functioning of such individuals within the com-
munity.
(5) COMMUNITY-ORIENTED HEALTH MEASURES
DEFINED.—As used in paragraph (1), the term
‘‘community-oriented health measures’’ includes ef-
forts to focus organized community activities upon
the promotion of health and the prevention of illness
and injury, support for self-help and mutual aid
groups offering health promotion and rehabilitative
support programs; surveillance of potential threats
to community health, and prompt action to protect
against such threats, and includes outreach efforts
to ensure that all residents are aware of and able to
utilize the health services of the Service, as needed.
(b) DISTRICT
RESPONSIBILITIES.—Each district
board shall periodically determine the necessity to estab-
lish and maintain in its district inpatient and other spe-
cialized health care facilities. Where found appropriate, it
shall establish and maintain in its district—
(1) a general hospital for the efficient and ef-
fective delivery of health care services to individuals
residing in the district requiring inpatient diagnosis,
treatment, care, and rehabilitation for injury or ill-
ness; and
(2) such other health care facilities as are nec-
essary, using guidelines established by the National
Health Board and by the respective regional board,
to promote the efficient and effective delivery of
health care services within its district.
In addition, each district board shall provide such health
care services of a specialized nature (whether delivered in
an inpatient or outpatient setting) as, taking into account
guidelines established by the National Health Board and
its respective regional board, may be provided most effec-
tively and efficiently at the district level.
(c) REGIONAL RESPONSIBILITIES.—Each regional
board shall, not later than the effective date of health serv-
ices, establish and maintain in its region—
(1) a regional medical facility for the efficient
and effective delivery of highly specialized health
care services, using guidelines established by the Na-
tional Health Board, to individuals residing in the
region requiring highly specialized treatment, care,
and rehabilitation for injury or illness;
(2) health care and supplemental services for
individuals whose health care needs otherwise cannot
be met by community or district boards because of
occupational or other factors, including individuals
residing within the region on a temporary or sea-
sonal basis (including migratory agricultural work-
ers) and individuals confined to prisons and other
correctional institutions; and
(3) such other health care facilities as are nec-
essary to promote the efficient and effective delivery
of health care services within its region.
(d) AREA HEALTH BOARD RESPONSIBILITIES.—
Each area health board, taking into account guidelines es-
tablished by the National Health Board, shall provide the
following through its health care facilities established pur-
suant to this section:
(1) Health promotion through education on per-
sonal health matters, nutrition, the avoidance of ill-
ness, and the effective use of health care services
with particular emphasis on the appropriate and safe
use (discouraging the overuse) of drugs and medical
techniques.
(2) Maintenance and appropriate transmission
and transferal of personal health records for each
user of the services of the board consistent with sec-
tion 201(9).
(3) Referral services, including referrals, where
appropriate, to health care facilities established by
other boards.
(4) Supplemental services (described in section
213(b)), as appropriate.
(5) Assistance to individuals who, because of
language or cultural differences or educational or
other handicaps, are unable fully to utilize the serv-
ices available from and delivered by the board.
(6) Information (A) on the rights ensured
under this Act, (B) on the guidelines and standards
established by the appropriate National Health
Board, and (C) on how the area health board is im-
plementing such rights and applying such guidelines
and standards.
(7) Information on the grievance mechanisms
established pursuant to subtitle A of title IV and on
legal services available to pursue grievances against
the board.
(8) Environmental health inspection and moni-
toring services, including investigations relating to
the prevention of communicable diseases, in coopera-
tion with State and local authorities in the board’s
area.
(9) Research and data-gathering on the leading
causes of ill-health and injury in the board’s area
and on health care delivery, in accordance with sec-
tion 421.
(10) In the case of each inpatient health care
facility, discharge planning and followup services (A)
to identify patients who will need continuing care
after discharge from the facility and (B) to plan,
with the patient and the patient’s family, arrange-
ments and referrals to meet such postdischarge
needs.
(e) AUTHORITIES.—
(1) EMPLOYMENT
OF
WORKERS.—Each area
health board shall, in establishing health care facili-
ties under this section, hire health workers (includ-
ing administrative personnel) in sufficient numbers
and with appropriate qualifications to ensure that
such facilities provide the health care and other serv-
ices described in this section. The regional board
shall be consulted in the hiring of all senior adminis-
trative and clinical personnel.
(2) FACILITIES.—In its establishment of health
care facilities under this section, each area health
board shall purchase or lease such premises as it
deems necessary and suitable, utilizing, where appro-
priate, existing health facilities, including health cen-
ters and clinics, hospitals, nursing homes, and med-
ical laboratories. The regional board shall be con-
sulted in the purchase or leasing of such facilities.
(3) EFFECTIVE
DELIVERY.—In its establish-
ment of health care facilities under this section, each
area health board shall seek to minimize fragmenta-
tion and duplication in delivery of health care and
other services so as to promote the effective and effi-
cient delivery of such services.
(4) COORDINATION.—Each regional board, tak-
ing into account guidelines established by the Na-
tional Health Board, shall provide for affiliation and
coordination of the operation and staff of the health
care facilities in its region with the operation and
staff of other appropriate health care facilities estab-
lished within the region such board serves and with-
in adjacent regions.
(5) ASSISTANCE TO COMMUNITY AND DISTRICT
HEALTH BOARDS.—Each regional board shall assist
the community and district health boards in its re-
gion in establishing and operating services. This
shall include providing for the education of health
workers under section 311, assistance in hiring all
health workers for the region, and assistance in pur-
chasing or leasing of such premises as it deems nec-
essary and suitable, in consultation with the appro-
priate community and district health boards in its
region.
(6) ASSURING
AVAILABILITY
AND
ACCESSI-
BILITY OF SERVICES.—Each regional board shall,
taking into account guidelines established by the Na-
tional Health Board, take whatever additional steps
are necessary to ensure that all of the health serv-
ices required under this title are available and acces-
sible in a timely manner to adults, infants, children,
and individuals with disabilities in its region. To-
ward that end, it shall—
(A) ensure that users within its region
have access to a sufficient number of each cat-
egory of health worker, including primary care
providers, specialists, and other health care pro-
fessionals, in a manner so that, to the max-
imum extent possible, such providers are geo-
graphically accessible to all residences and
workplaces within the region and are culturally
and linguistically appropriate;
(B) ensure that services are available in a
manner which ensures continuity of care, avail-
ability within reasonable hours of operation,
and include emergency and urgent care services
which shall be accessible at all times within the
service area;
(C) ensure that any process established to
coordinate care shall ensure ongoing direct ac-
cess to relevant specialists and shall not impose
an undue burden on users with chronic health
conditions;
(D) ensure that appropriate steps are
taken to eliminate any transportation or other
barriers to the timely receipt of services;
(E) ensure that a user who has a severe,
complex, or chronic condition shall have access
to the most appropriate health care coordinator
(as defined in paragraph (7)(A)); and
(F) ensure that priorities in the use of
services and facilities shall be set by the appro-
priate health care professionals using criteria of
medical necessity and that any limitations or
delay in access to services shall be based only
on limits of available service personnel and
physical facilities.
(7) DEFINITIONS.—For purposes of this sub-
section:
(A) HEALTH
CARE
COORDINATOR.—The
‘‘health care coordinator’’ means a health work-
er who performs case management (as defined
in subparagraph (B)) functions in consultation
with the health care team, the patient, family,
and community.
(B) CASE MANAGEMENT.—The term ‘‘case
management’’ means a coordinated set of activi-
ties conducted for the management of an indi-
vidual user’s serious, complicated, protracted or
chronic health conditions in order to ensure
cost-effective and benefit-maximizing treatment.
(f) GUIDELINES.—The National Health Board shall
establish guidelines for distribution and coordination of
the delivery of health care and other services described in
this section and shall, before the effective date of health
services, plan and facilitate the transition to the new dis-
tribution of health care facilities and health workers to
be effected on and after that date.
(g) USE OF EVIDENCE-BASED CLINICAL DECISION
CRITERIA.—
(1) IN GENERAL.—The National Health Board
shall authorize the National Institute of Evaluative
Clinical Research described in section 422 to estab-
lish evidence-based clinical decision criteria, where
feasible, that shall apply throughout the Nation.
(2) CLINICAL DECISION CRITERIA DEFINED.—
For purposes of this section, the term ‘‘clinical deci-
sion criteria’’ means the recorded (written or other-
wise) screening procedures, decision abstracts, clin-
ical protocols, and practice guidelines used as an im-
portant basis to determine the necessity and appro-
priateness of health care services, in combination
with the facts of particular cases, the judgment of
health care professionals, and the preferences of
users. Such criteria shall be clearly documented and
available to all health workers and shall include a
mechanism for periodically updating such criteria.
(h) NOTICE
OF DETERMINATIONS.—Each health
board shall provide users with timely notice of any deter-
mination to provide, deny, or delay provision of a service,
and information about the relevant clinical decision cri-
teria upon which such determination is based, if any. Such
notification shall include information concerning the ap-
propriate procedure to appeal such decision.
(i) ACCOUNTABILITY.—In the case that a community
or district board fails, on the effective date of health serv-
ices, to substantially and materially provide health care
and supplemental services in accordance with this section,
its respective regional board shall take such steps as it
deems necessary, consistent with the provisions of section
402 (relating to grievance proceedings), to provide health
care and supplemental services to users in the community
or district affected. Such steps may include, in addition
to appointment of a trustee or trustee committee under
section 402(d)(3)(D)—
(1) requiring that the community or district
board in an adjacent community or district provide
such services to users residing in the community or
district affected, or
(2) providing reimbursement for the provision
of specified health care services in accordance with
procedures and schedules in effect under title XVIII
of the Social Security Act immediately before the ef-
fective date of health services (except that only users
in the affected community or district shall be consid-
ered as entitled to receive such specified services
under such title).
Paragraph (2) shall not apply on and after three years
after the effective date of health services.
SEC. 222. OPERATION AND INSPECTION OF HEALTH CARE
FACILITIES.
(a) ESTABLISHMENT OF POLICIES.—
(1) IN GENERAL.—Each health board, with re-
spect to each health care facility it has established,
shall establish policies and organizational plans con-
sistent with this section and with parts A and C of
title III (relating to the health labor force) for the
operation of such facility and shall establish proce-
dures to ensure that the facility is operated in ac-
cordance with such policies and plans.
(2) INPUT.—In establishing, implementing, and
modifying such policies and plans, each health board
shall seek the fullest possible participation of health
workers who are employed in, and users who receive
health care services from, health care facilities af-
fected by such policies and plans.
(3) HEALTH
FACILITY
BOARDS.—If a health
board that has established more than one health
care facility determines that it cannot itself effec-
tively manage the operation of all such facilities or
if a facility serves principally a population with spe-
cial health needs which is not appropriately rep-
resented on the health board, the health board may
provide for the establishment of a health care facility
board or boards, composed of users and health work-
ers (or representatives of users or workers of a facil-
ity or facilities) in an appropriate number and in a
proportion approximating that on the health board,
to assume the duties of the health board with re-
spect to the operation of the facility or facilities in-
volved.
(b) GENERAL POLICY.—Such policies and plans shall
provide for—
(1) the management of each facility by the
workers in such facilities through mechanisms which
provide full participation of health workers of all job
categories and skill levels employed in such facility;
(2) the elimination of dominance by health pro-
fessionals and the encouragement of cooperation and
mutual respect among all health workers; and
(3) regular accountability of the health workers
to the health board which established the facility for
the efficient and effective operation of the facility.
(c) PRIVATE DELIVERY.—
(1) RESTRICTIONS.—On and after 3 years after
the effective date of health services, a health board
may not permit a health care facility it has estab-
lished to be used for the private delivery of inpatient
or outpatient health care services.
(2) EMPLOYMENT
RESTRICTIONS.—No indi-
vidual employed by a health board may engage in
the private delivery of health care services.
(3) PRIVATE
DELIVERY
OF
HEALTH
CARE
SERVICES DEFINED.—For the purposes of this sub-
section, the term ‘‘private delivery of health care
services’’ means the delivery of health care services
for which an individual, group, or organization re-
ceives remuneration from any source other than the
Health Service Trust Fund established in section
511.
(d) HOURS OF OPERATION.—Each health board shall
ensure that any health care facility that it operates which
provides health care services on an outpatient basis is open
during hours that will permit all users to make use of such
services.
(e) INPATIENT SERVICES.—
(1) ADEQUATE CARE.—Each health board shall
ensure that any health care facility that it operates
which provides (or is designed to provide) substan-
tial health care services on an inpatient basis to in-
dividuals over a continuous period of 30 days or
longer—
(A)(i) provides comfortable living quarters
for inpatients that are clean and adequately
heated, cooled, and ventilated;
(ii) provides adequate staff for its inpa-
tients;
(iii) provides nutritional food for its inpa-
tients;
(iv) provides inpatients with opportunities
for creative activity and recreation;
(v) establishes and maintains a review
committee in accordance with paragraph (2);
and
(vi) informs an inpatient of all decisions
involving the inpatient’s health and well-being
and permits the inpatient (and the review com-
mittee upon the inpatient’s request) to partici-
pate fully in such decisions;
(B) and does not—
(i) censor or harass communication
between an inpatient and others by tele-
phone, letter, or in person;
(ii) confiscate personal property of an
inpatient, unless possession of such prop-
erty would interfere with the provision of
health care;
(iii) deny an inpatient the social and
sexual life of such individual’s preference;
(iv) require that an inpatient work;
(v) pay an inpatient less than min-
imum wage for work performed while re-
ceiving health care services;
(vi) physically restrain an inpatient
involuntarily for a period exceeding 72
hours without the facility’s review com-
mittee (described in paragraph (2)) deter-
mining, within 72 hours of its initiation
and not less often than every 2 weeks dur-
ing which such restraint is continued, that
such restraint is required for the physical
safety of the inpatient or of others; or
(vii) take punitive or discriminatory
action (including transfer between or with-
in facilities, changes in physical comforts
and diets, changes in opportunities for so-
cial interaction and communication, or re-
striction of full participation in rec-
reational and creative activities) without
the prior approval, and renewed approval
not less often than every week thereafter,
of the facility’s review committee (de-
scribed in paragraph (2)).
(2) INPATIENT REPRESENTATIVES.—
(A) ELECTION.—Each health board shall
provide that at least once each year the inpa-
tients at that time of each health care facility
it operates which provides (or is designed to
provide) health care services on an inpatient
basis to individuals over a continuous period of
30 days or longer shall elect, from among them-
selves and any representatives of user associa-
tions which have a demonstrated interest in the
care of such inpatients, a review committee (in
this paragraph referred to as the ‘‘committee’’)
of not less than 3 members.
(B) RECALL.—Any member of the com-
mittee may be recalled by a vote of two-thirds
of the number of inpatients in the facility.
(C) VOTING.—In the case of any election
or recall under this paragraph any inpatient
who is not able to vote for any reason shall be
permitted to appoint another individual to vote
as proxy.
(f) INSPECTIONS.—In order to assure that quality
care is provided in health care facilities of the Service—
(1) each area health board shall conduct reg-
ular inspections of health care facilities it has estab-
lished,
(2) each regional board shall conduct regular
inspections of district and community health care fa-
cilities established in its region, and
(3) the National Health Board shall conduct
regular inspections of area and national health care
facilities,
and the results of such inspections of a facility shall be
reported to the appropriate area health board and users
of the facility and shall be made available to the public.
SEC. 223. PROVISION OF HEALTH SERVICES RELATING TO
REPRODUCTION AND CHILDBEARING.
(a) PROVISION OF SERVICES.—
(1) FAMILY PLANNING.—Area health boards, as
appropriate, shall provide the following services:
(A) Complete information on contraception
and provision of birth control materials or
medication of the individual’s choosing.
(B) Complete and effective evaluation and
treatment of venereal diseases and diseases of
the reproductive organs.
(C) Complete information and counseling
with respect to pregnancy, childbearing, and
possible outcomes involving genetically induced
anomalies.
(2) PREGNANCY.—Area health boards, as ap-
propriate, shall provide the following services:
(A) Complete and effective pregnancy test-
ing.
(B) Prenatal services, including physical
examination, counseling, and instruction of ex-
pectant parents in nutrition, childrearing, and
children’s health care services.
(C) Safe, comfortable, and convenient
abortion services.
(D) Counseling for women in conjunction
with the provision of all gynecologic, female
contraceptive, and abortion services and coun-
seling for men on male fertility-related services.
(3) VOLUNTARY.—The services described in
paragraphs (1) and (2) shall be delivered without co-
ercion or harassment, with complete confidentiality,
and without prior approval of individuals other than
the individual receiving the services.
(4) ACCOMPANIMENT.—An individual shall be
permitted to be accompanied by a person of the indi-
vidual’s choice during the provision of the services
described in paragraphs (1) and (2) to the extent
this would not significantly increase the medical risk
to the individual.
(b) VOLUNTARY CONSENT.—No area health board
may perform upon an individual a treatment or procedure
(other than a treatment or procedure required to preserve
the life of the individual) which could reasonably be ex-
pected to affect the individual’s capacity to reproduce chil-
dren, unless—
(1) the individual has given voluntary written
consent to the treatment or procedure after being
given complete information on the effect of the
treatment or procedure on the individual’s reproduc-
tive capacity, and on possible alternative treatments
and procedures, at least 30 days before beginning
the treatment or procedure, and
(2) the individual has, after such 30-day wait-
ing period, again given written consent to the per-
formance of the treatment or procedure, except that
in the case of a woman who has given initial written
consent to a sterilization she may be sterilized in
less than 30 days following such consent (but in no
case in less than 72 hours)—
(A) if she had given initial written consent
at least 30 days before her anticipated delivery
date, she delivers before the anticipated date,
and the sterilization is performed at the time of
delivery;
(B) if she undergoes emergency abdominal
surgery within the 30-day waiting period and
the sterilization is concurrent with the abdom-
inal surgery; or
(C) in the case of an elective sterilization
procedure, such as tubal ligation or vasectomy,
that is scheduled and performed separately
from the act of childbirth, where prior informed
consent is provided and the procedure is per-
formed at the next subsequent or any later
medical visit after informed consent is obtained.
(c) BREAST CANCER TREATMENT.—An area health
board shall insure that, before a mastectomy or other
breast cancer treatment is performed on a woman, the
woman shall be provided with complete information on the
complete range of medical options available for treatment
of her condition and the risks and side effects of each op-
tion and an opportunity to consult individuals of her
choice, and shall have given voluntary written consent to
such procedure.
(d) BIRTHING OPTIONS.—An area health board shall
provide that a woman giving birth to an infant shall have
the right to choose from a complete range of childbirth
options including—
(1) giving birth at home, in a birth center (if
available), or in a hospital;
(2) the presence during childbirth of a person
or persons of her choosing;
(3) the position for labor and delivery which she
chooses;
(4) caring for her infant at her bedside;
(5) feeding her infant according to the method
and schedule of her choice; and
(6) selecting the birth attendant of her own
choice.
She shall be provided with information on the benefits,
risks, and side effects of each option and an opportunity
to consult individuals and groups of her choosing for infor-
mation and assistance on these options.
TITLE III—HEALTH LABOR
FORCE
Subtitle A—Job Categories and
Certification
SEC. 301. EFFECT OF STATE LAW.
Notwithstanding any law of a State or political sub-
division to the contrary, the Service, acting in accordance
with the provisions of this Act, shall be the sole judge of
the qualifications of its employees.
SEC. 302. QUALIFICATIONS OF HEALTH WORKERS.
(a) CERTIFICATION OF COMPETENCE.—Each area
health board shall, taking into account guidelines estab-
lished by the National Health Board, establish procedures
which will ensure that, except in emergency situations, any
work which is classified under a job category established
under this subtitle is performed by a health worker who
at the time of such work was—
(1) certified (in accordance with this subtitle)
as competent to perform the work under such job
category, and
(2) authorized to perform such work by the
area health board which employs such worker.
(b) PERIODIC
ASSESSMENTS.—Each area health
board that employs health workers who perform work clas-
sified under a job category established under this subtitle
shall provide for the periodic review and assessment of the
competency of such workers to perform the work within
such job category, and shall provide opportunities for
health workers to be assessed and certified with respect
to skills required for advancement to other job categories.
(c) OTHER PERIODIC REVIEWS.—In order to assure
that health workers provide high quality health care serv-
ices in the Service—
(1) each regional board shall provide for peri-
odic review and assessment of the performance of
health workers employed by district and community
boards in its region, and
(2) the National Health Board shall provide for
periodic review and assessment of the performance
of health workers employed by regional boards and
the National Health Board,
and the results of such examinations of health workers
shall be reported to the appropriate area health board and
the users residing in the areas in which the health workers
are employed and shall be made available to the public.
SEC. 303. ESTABLISHMENT OF JOB CATEGORIES AND CER-
TIFICATION STANDARDS.
(a) IN GENERAL.—
(1) CLASSIFICATION.—The National Health
Board shall establish such guidelines for the classi-
fication, certification, and employment of health
workers by job category as it determines to be
necessary—
(A) to ensure that health workers who per-
form work for the Service which requires spe-
cialized skills have demonstrated that they pos-
sess such skills,
(B) to expand the roles of health workers
to enable them to participate in health care de-
livery to the maximum extent consistent with
their skills, and
(C) to provide for affiliation of health
workers with health care facilities at the com-
munity, district, and regional levels.
These guidelines shall permit alternative approaches
to healing, and practitioners skilled in such ap-
proaches, when these approaches have not been dem-
onstrated to be injurious to health.
(2) CONSIDERATIONS.—In establishing guide-
lines under paragraph (1), the National Health
Board shall provide for (A) sufficient flexibility to
100
permit regional health boards to utilize health work-
ers most effectively to meet the health needs of the
region, and (B) sufficient uniformity to permit mo-
bility of health workers among the regions.
(3) 
LOCAL
EMPLOYMENT.—In 
establishing
guidelines under paragraph (1)(C), and as appro-
priate to the job responsibilities of the respective
health workers, the National Health Board shall re-
quire that each health worker employed by a com-
munity board must work part of the time in a health
care facility operated by the respective district or re-
gional board, and that each health worker (including
the faculty of health team schools) employed by a
district or regional board must work part of the time
in a health care facility operated by a community
board within the district or region.
(4) PERIODIC
EVALUATION.—The National
Health Board shall periodically evaluate the job cat-
egories and certification practices established by
area health boards under this section and shall make
such modifications to its guidelines as it determines
will promote the delivery of quality health care serv-
ices.
(5) NATIONAL BOARD ASSISTANCE.—The Na-
tional Health Board shall assist regional boards in
101
applying the guidelines established under this sub-
section.
(b) CERTIFICATION STANDARDS.—
(1) ESTABLISHMENT.—For each job category
(other than a job category determined by the Na-
tional Health Board to involve highly specialized
skills requiring advanced specialty training), each re-
gional health board shall, taking into account the
guidelines established under subsection (a), establish
certification standards which shall specify—
(A) 
the 
functions 
performed 
by 
a
healthworker employed in such job category;
(B) the skills required in the course of
properly performing work under such job cat-
egory;
(C) the initial and continuing training, ex-
perience, and performance which must be un-
dertaken or demonstrated by a health worker to
achieve and maintain competency to perform
the work within such job category; and
(D) the curriculum which a health worker
must follow in studies in a health team school
(established under subtitle B) to demonstrate
sufficient competence to satisfy the specification
of subparagraph (C) for such job category.
102
Each area health board within the region shall apply
such standards to all health workers employed by it.
In applying such standards, such boards shall recog-
nize health worker training, experience, and per-
formance undertaken or demonstrated before the es-
tablishment of health team schools under subtitle B,
subject to such periodic review and assessment and
to such continuing training, experience, or perform-
ance as may be required under this subtitle.
(2) SPECIFICATIONS.—For each job category
established and determined by the National Health
Board to involve highly specialized skills requiring
advanced specialty training, the National Health
Board shall make the specifications described in sub-
paragraphs (A) through (D) of paragraph (1), and
area health boards shall apply such certification
standards to all health workers employed by them in
such job categories.
(3) PERIODIC REVIEW.—A health board which
establishes standards for a job category under this
subsection shall periodically review such standards
and shall supplement, modify, or eliminate such
standards as it determines will facilitate the delivery
of quality health care services under this Act.
(4) QUALITY PROTECTION.—
103
(A) PROHIBITION
OF
DOWNGRADES
OF
LEVELS.—No individual health facility adminis-
trator is authorized to downgrade the level of
skill, license or certification required to perform
duties delineated by the Board.
(B) REVIEW.—
(i) REVIEW OF STAFFING CHANGES.—
Upon enactment of this Act, the Board
shall convene a national level task force to
review the impact on the safety and health
of patients and workers of downgrading
and deskilling of health care job categories
by replacing licensed with unlicensed work-
ers during the 1990s, particularly in the
nursing area, and to recommend remedies
as appropriate.
(ii) WHISTLEBLOWER PROTECTION.—
Health care workers who report com-
promises in the quality of care shall not be
subjected to recriminations.
(C) WORKFORCE STAFFING LEVELS.—The
Board may establish health workforce staffing
levels, or delegate that power to regional or dis-
trict health boards, as it determines will pro-
mote the delivery of quality health care services.
104
Subtitle B—Education of Health
Workers
SEC. 311. HEALTH TEAM SCHOOLS.
(a) ESTABLISHMENT.—
(1) IN GENERAL.—Except as provided in para-
graph (2), each regional board, in consultation with
the community and district boards in its region,
shall establish a health team school (hereinafter in
this subtitle referred to as a ‘‘school’’) in accordance
with this section to provide programs of initial and
continuing basic education in health care delivery for
health workers in all job categories, and to provide
initial continuing advanced education in health care
specialties and health science specialty fields. Each
school shall be established and functioning not later
than 4 years after the effective date of health serv-
ices unless the National Health Board approves a
plan, submitted by the regional board, for the estab-
lishment of a school within a reasonable time after
such deadline.
(2) SUBSTITUTION OF COLLABORATION.—If a
regional board determines, after consultation with
the community and district boards in its region, that
conducting particular educational programs within a
school in its region would be inefficient or otherwise
105
inappropriate, it may collaborate with one or more
regional boards for adjacent regions conducting joint
educational programs. In the case of the establish-
ment of such a joint program, all further references
in this subtitle to a region or a regional board with
respect to a school offering a joint program shall
refer to the regions included within, and the regional
boards offering, the joint program.
(3) USE OF FUNDS.—Schools shall be funded
exclusively by the Service, shall not charge nor ac-
cept tuition or fees for enrollment, and shall provide
each student with an adequate allowance for living
expenses, educational supplies, and any child care
expenses.
(4) NATIONAL BOARD ASSISTANCE.—The Na-
tional Health Board shall assist regional boards in
the establishment and maintenance of schools.
(b) OPERATIONAL PRINCIPLES.—Schools shall be op-
erated and maintained in accordance with the following
principles:
(1) The activities of each school shall be de-
signed to meet the health needs of the region, dis-
tricts, and communities which it serves.
(2) The number of students enrolled in each
educational program in a school shall be based on
106
the regional, district, and community boards’ assess-
ments of the needs for health workers within such
region, districts, and communities.
(3) Schools shall integrate the education of
health workers in the different job categories (estab-
lished under subtitle A) so as to permit health work-
ers to be educated and certified for successively
higher levels of health care work.
(4) Each school’s admissions policies, cur-
riculum policies, faculty hiring procedures, and gov-
ernance plan shall be established and implemented
by the regional board in accordance with subsections
(c) through (f), respectively, and with the fullest
possible participation of the community and district
boards, health workers, staff, and students in its re-
gion.
(5) A school may not use individuals who are
from low-income populations or minority groups, or
who are women or confined in mental or penal insti-
tutions, as subjects for training or demonstration in
numbers that are disproportionate to their numbers
in the population of the region, and may not use any
individuals as subjects for training or demonstration
in a manner beyond that required for the immediate
107
purpose of the training or demonstration or without
their explicit consent.
The National Board shall establish, not later than one
year after the effective date of health services, guidelines
for the application of these principles and for the phased
integration of health worker education programs, includ-
ing medical, dental, osteopathic, and nursing school pro-
grams, in existence on the date of enactment of this Act
into the schools established under this section.
(c) ADMISSIONS POLICIES.—Each regional board
shall establish and implement admissions policies for edu-
cation programs in its school. Such policies shall—
(1) emphasize previous health-related work ex-
perience, as evaluated by health workers (including
peers), by individuals who have received health care
services from the applicant, and by faculty members;
(2) minimize the use of criteria of academic
performance other than such criteria as have been
shown to be significantly related to future work per-
formance;
(3) give preference to segments of the popu-
lation of the region under-represented among health
workers;
(4) to the extent consistent with paragraph (3),
provide for admission of individuals so that the stu-
108
dent body approximates the population of the region
by race, sex, family income, and language; and
(5) require that the applicant agree, if accepted
into the school, to perform health care services in ac-
cordance with section 312.
(d) CURRICULUM POLICIES.—Each regional board
shall establish and implement curriculum policies for edu-
cational programs in its school. Such policies shall—
(1) give priority in study and field work to the
leading causes of illness and death in the region, in-
cluding environmental, biological, and social deter-
minants of mortality and morbidity;
(2) give special consideration to studying the
social, as well as biological, causation and prevention
of illness and disease, and to the differing health
care needs of populations facing special health risks
and having special cultures and lifestyles within the
region;
(3) provide that all students shall take a com-
mon, initial sequence of courses and that students
preparing for more advanced types of health work
shall take studies that are progressively more spe-
cialized and differentiated;
(4) emphasize work-study experience in all
types of health care facilities in the region, including
109
community and workplace facilities, facilities for the
aged, mentally ill, and mentally retarded, health care
facilities in prisons and other correctional institu-
tions, alcohol and drug rehabilitation facilities, envi-
ronmental health facilities, and all other health care
facilities of the Service in communities and districts
in the region;
(5) emphasize the appropriate and safe use,
and discourage the overuse, of drugs and medical
techniques; and
(6) facilitate the development by all health
workers of skills in decisionmaking and assessment
of user needs in cooperation with other health work-
ers and with users.
(e) FACULTY HIRING PROCEDURES.—Each regional
board shall establish and implement faculty hiring proce-
dures for its school. Such procedures shall, to the max-
imum extent feasible, create a faculty which approximates
the population of the region by race, sex, and language.
(f) GOVERNANCE PLANS.—Each regional board shall
establish and implement a governance plan for the man-
agement of its school. Such plan shall give significant deci-
sionmaking powers to staff and students of the school.
SEC. 312. SERVICE REQUIREMENT.
(a) SERVICE REQUIREMENT.—
110
(1) IN GENERAL.—No individual may be en-
rolled by a regional board in a school unless the in-
dividual agrees to perform health care services as an
employee of the Service in the job category for which
training is being provided—
(A) for a period of time equal to the period
of such enrollment in the school but not less
than 2 years;
(B) beginning not later than 1 year after
the date of the individual’s graduation from the
school; and
(C) for an area health board with the high-
est priority ranking under subsection (c) that
agrees to employ the individual.
(2) DEFERRAL.—An individual’s obligation to
perform service under an agreement described in
paragraph (1) shall be deferred only for a period
during which the individual is physically or mentally
incapable of performing such service.
(3) COMPLETION OF SERVICE REQUIRED.—No
health board may employ an individual who has
made an agreement described in paragraph (1),
other than in accordance with subsection (c), until
the individual has completed the period of obligated
service in accordance with this section.
111
(4) PENALTY FOR BREACH OF AGREEMENT.—
Except as provided in paragraph (5), if an individual
breaches an agreement under paragraph (1) by fail-
ing (for any reason) either to begin such individual’s
service obligation or to complete such service obliga-
tion, the Service shall be entitled to recover from the
individual an amount determined in accordance with
the formula
A=φ + 1¥
s
,
t
.
in which ‘‘A’’ is the amount the Service is entitled
to recover; ‘‘φ’’ is an amount determined by the Na-
tional Health Board to be the costs to the Service
of the education program and allowance received by
the individual and the interest on such costs which
would be payable if at the time the costs were under-
taken they were loans bearing interest at the max-
imum legal prevailing rate, as determined by the
Treasurer of the United States; ‘‘t’’ is the total
number of months in the individual’s period of obli-
gated service; and ‘‘s’’ is the number of months of
such period served by the individual. Any amount of
damages which the Service is entitled to recover
under this paragraph shall, within the 1-year period
112
beginning on the date of the breach of the agree-
ment, be paid to the Service.
(5) CANCELLATION.—
(A) UPON DEATH.—Any obligation of an
individual under this subsection for service or
payment of damages shall be canceled upon the
death of the individual.
(B) EXTREME
HARDSHIP
EXCEPTION.—
The National Health Board shall provide for
the waiver or suspension of any obligation of
service or payment by an individual under this
subtitle whenever compliance by the individual
is impossible or would involve extreme hardship
to the individual and if enforcement of such ob-
ligation with respect to any individual would be
unconscionable.
(C) LIMITATION ON DISCHARGE IN BANK-
RUPTCY.—Any obligation of an individual under
this subtitle for payment of damages may be re-
leased by a discharge in bankruptcy under title
11 of the United States Code only if such dis-
charge is granted after the expiration of the 5-
year period beginning on the first date that
payment of such damages is required.
113
(b) PERIODIC REASSESSMENT
OF WORKER RA-
TIOS.—Each area health board shall periodically assess
the ratio of the number of health workers employed by
the board in each job category (established under subtitle
A) to the number of residents in the area.
(c) PRIORITY RANKING.—
(1) IN
GENERAL.—With respect to an indi-
vidual obligated to perform service under this section
as a result of completion of an educational program
for a job category in a school, the priority ranking
(referred to in subsection (a)(1)(C)) of area health
boards for hiring the individual is as follows:
(A) The regional board for the region, or
a district or community board for a district or
community in the region, in which the program
was completed, if the region, district, or com-
munity is a health worker shortage area (as de-
fined in paragraph (2)) with respect to the job
category for which the individual received train-
ing.
(B) A regional, district, or community
board (other than one described in subpara-
graph (A)) for a region, district, or community
which is a health worker shortage area with re-
114
spect to the job category for which the indi-
vidual received training.
(C) Any other area health board.
(2) HEALTH
WORKER
SHORTAGE
AREA
DE-
FINED.—For the purposes of paragraph (1), the
term ‘‘health worker shortage area’’ means, with re-
spect to a job category for which an individual has
received training in a school, a region, district, or
community which—
(A) has a ratio of the number of health
workers in the job category employed by the re-
gional, district or community board, respec-
tively, to the number of residents in the region,
district, or community (whichever is applicable)
which is less than two-thirds of the ratio of the
total number of health workers in the job cat-
egory employed by all the regional, district, or
community boards, respectively, in the Nation
to the number of residents in the Nation, and
(B) has plans and a budget which provide
for the hiring of an individual in the job cat-
egory.
(3) WORKER MATCHES.—The National Health
Board shall establish a program to match the loca-
tional preferences of graduates of schools with the
115
needs and preferences of regional, district, and com-
munity boards.
SEC. 313. PAYMENT FOR CERTAIN EDUCATIONAL LOANS.
(a) LOAN PAYMENT PROGRAM.—In the case of any
individual who has incurred any educational loan before
the fourth year after the effective date of health services
and for the individual’s costs for an educational program
in health care delivery, health care specialties, or health
science specialty fields, the National Health Board shall
make payments, in accordance with subsection (b), for and
on behalf of that individual, on the principal of and inter-
est on any such loan which is outstanding on the date the
individual begins to work for the Service.
(b) MAKING OF PAYMENT.—The payments described
in subsection (a) shall be made by the National Health
Board as follows:
(1) Upon completion by the individual for whom
the payments are to be made of the first year of em-
ployment with the Service, the National Health
Board shall pay 30 percent of the principal of, and
the interest on, each loan described in subsection (a)
which is outstanding on the date he began such em-
ployment.
(2) Upon completion by that individual of the
second year of such employment, the National
116
Health Board shall pay another 30 percent of the
principal of, and the interest on, each such loan.
(3) Upon completion by that individual of a
third year of such employment, the National Health
Board shall pay another 25 percent of the principal
of, and the interest on, each such loan.
(4) Upon completion by that individual of a
fourth year of such employment, the National
Health Board shall pay the remaining 15 percent of
the principal of, and all remaining interest on, each
such loan.
No payment may be made under this subsection with re-
spect to a loan unless the person on whose behalf the pay-
ment is to be made has submitted to the National Health
Board a certified copy of the agreement under which such
loan was made.
(c) PAYMENT
DURING
EMPLOYMENT.—Notwith-
standing the requirement of completion of employment
specified in subsection (b), the National Health Board
shall on or before the due date thereof, pay any loan or
loan installment which may fall due within the period of
employment for which the borrower may receive payments
under this section, upon the declaration of such borrower,
at such times and in such manner as the National Health
Board may prescribe (and supported by such other evi-
117
dence as the National Health Board may reasonably re-
quire), that the borrower is then employed as described
in subsection (b) and that the borrower will continue to
be so engaged for the period required (in the absence of
this subsection) to entitle the borrower to have made the
payments provided by this section for such period, except
that not more than 85 percent of the principal of any such
loan shall be paid pursuant to this subsection.
Subtitle 
C—Employment 
and
Labor-Management 
Relations
Within the Service
SEC. 321. EMPLOYMENT, TRANSFER, PROMOTION, AND RE-
CEIPT OF FEES.
(a) SERVICE EMPLOYEES.—Health boards shall, in
accordance with this Act and taking into account guide-
lines and standards established by the appropriate Na-
tional Health Board, employ, classify, and fix the salaries
and benefits of all employees of the Service employed in
the Service’s facilities.
(b) POLICIES.—The appropriate National Health
Board, in establishing guidelines and standards under this
subtitle, shall, to the extent feasible and consistent with
the provisions of this subtitle, provide for—
118
(1) employment and promotion in the Service in
the same manner as is provided for employment and
promotion under the Federal civil service system;
(2) meaningful opportunities for career ad-
vancement;
(3) encouragement of health workers to use up
to 10 percent of their work time for continuing edu-
cation under subtitle B without loss of pay or other
job rights; and
(4) full protection of employees’ rights by pro-
viding an opportunity for a fair hearing on adverse
actions with representation of their own choosing.
(c) HIRING PREFERENCES.—Health boards, in hiring
employees to fill vacancies in newly created positions, shall
give preference to individuals who were employed as health
workers, or self-employed while delivering health services,
before the date of enactment of this Act. The National
Health Board shall ensure, through such steps as it deems
necessary, that all such individuals desiring to be em-
ployed within the Service shall find appropriate employ-
ment in the Service.
(d) PROMOTION AND TRANSFER.—Employees of the
Service shall be eligible for promotion or transfer to any
position in the Service for which they are qualified. Each
regional board shall establish and maintain a job place-
119
ment service to assist health workers in its region in iden-
tifying suitable employment opportunities and in transfer-
ring between jobs with different area health boards in the
region. The authority given by this subsection shall be
used to provide a maximum degree of career opportunities
for employees and to ensure continued improvement of
health care services.
(e) VACANCIES.—A community or district board may
not hire an individual to fill a job vacancy that is classified
under subtitle A in a job category if—
(1) the community or district board, respec-
tively, has a ratio of the number of health workers
in the job category employed by such board to the
number of residents in the community or district
(whichever is applicable) which is greater than four-
thirds of the ratio of the total number of health
workers in the job category employed by all the com-
munity or district boards, respectively, in its region
to the number of residents in such region; and
(2) there is a community or district within its
region which is a health worker shortage area (as
defined in section 312(c)(2)) with respect to the job
category.
(f) NO UNDUE FINANCIAL INCENTIVES.—No health
worker should benefit financially from the provision or de-
120
nial of services to individual patients, beyond their regular
remuneration.
(g) SOLE EMPLOYER.—An employee of the Service
may not receive any fee or perquisite on account of duties
performed by virtue of such employment, except from a
health board established under this Act.
(h) GRANDFATHER CLAUSE.—The National Board
shall support alternative procedures to assure that health
care professionals meet required standards, particularly
those currently practicing in health professional shortage
areas in inner cities and in rural communities.
(i) TRANSITIONAL EMPLOYMENT.—Up to 1 percent
of the budget of the United States Health Service for each
of its first 2 years may be expended for the retraining
and hiring of sales, administrative, clerical, and service
employees displaced as a result of this Act, including those
in the health insurance industry.
SEC. 322. APPLICABILITY OF LAWS RELATING TO FEDERAL
EMPLOYEES.
(a) IN GENERAL.—Chapter 75 of title 5, United
States Code (relating to adverse actions against employ-
ees), apply to employees of the Service (other than employ-
ees serving on the personal staff of members of health
boards) except to the extent provided—
121
(1) in a collective-bargaining agreement nego-
tiated on behalf of and applicable to them; or
(2) in procedures established by the Service and
approved by the Office of Personnel Management.
(b) COVERAGE UNDER WORKERS COMPENSATION.—
Employees of the Service are covered by subchapter I of
chapter 81 of title 5, United States Code (relating to com-
pensation for work injuries).
(c) CIVIL SERVICE.—
(1) APPLICATION
OF
CIVIL
SERVICE
RETIRE-
MENT.—Chapter 83 of title 5, United States Code
(relating to civil service retirement), applies to em-
ployees of the Service except to the extent provided
in a collective-bargaining agreement negotiated on
behalf of and applicable to them.
(2) WITHHOLDING.—The Service shall withhold
from pay and shall pay into the Civil Service Retire-
ment and Disability Fund the amounts specified in
chapter 83 of title 5, United States Code, as re-
quired under paragraph (1). The Service, upon re-
quest of the Office of Personnel Management, but
not less frequently than annually, shall pay to the
Office the costs reasonably related to the adminis-
tration of Fund activities for employees of the Serv-
ice.
122
(d) ACCRUAL OF SICK AND ANNUAL LEAVE.—Sick
and annual leave and compensatory time of employees of
the Service, whether accrued prior to or after the com-
mencement of operations of the Service, shall be obliga-
tions of the Service.
(e) APPLICATION OF CONDITIONS.—
(1) TERMS OF EMPLOYMENT.—Compensation,
benefits, and other terms and conditions of employ-
ment in effect on the effective date of health services
for employees of the Federal Government performing
functions that are provided under this Act by the
Service, shall apply to all employees of the Service
performing similar functions until changed by the
Service in accordance with this Act. Subject to the
provisions of this Act, the provisions of subchapter
I of chapter 85 and chapter 87 of title 5, United
States Code (relating to unemployment compensa-
tion and life insurance), apply to employees of the
Service unless varied, added to, or substituted for in
accordance with paragraph (2).
(2) LIMITATION ON VARIATION.—No variation,
addition, or substitution with respect to fringe bene-
fits shall result in a program of fringe benefits which
on the whole is less favorable to employees of the
Service than fringe benefits in effect for employees
123
of the Federal Government on the effective date of
health services. No variation, addition, or substi-
tution with respect to fringe benefits of employees
for whom there is a collective-bargaining representa-
tive shall be made except by agreement between such
representative and the Service.
SEC. 323. APPLICABILITY OF FEDERAL LABOR-MANAGE-
MENT RELATIONS LAWS.
(a) APPLICATION OF NLRA.—
(1) IN GENERAL.—The provisions of the Na-
tional Labor Relations Act (42 U.S.C. 141 et seq.)
shall apply to the Service and its employees to the
extent, not inconsistent with subsection (b), to which
such provisions apply to employers (as defined in
section 2(2) of such Act), except that—
(A) the phrase ‘‘or any individual employed
as a supervisor’’ in section 2(3) of such Act
shall not apply (thereby making such Act apply,
for these purposes, to such individuals);
(B) section 9(b)(1) of such Act (providing
for separate treatment for professional and
nonprofessional employees) shall not apply;
(C) sections 206 through 210 of such Act
(relating to national emergencies) shall, for pur-
poses of this Act, have the phrases ‘‘the Presi-
124
dent of the United States’’ and ‘‘the Presi-
dent’’, wherever they appear, replaced by the
phrase ‘‘the National Health Board (or a com-
mittee thereof to which it has delegated such
authority)’’ and the phrase ‘‘national health or
safety’’ replaced by the phrase ‘‘health or safety
of the residents of any region’’; and
(D) section 213 (providing for intervention
in a strike or lockout by the Director of the
Federal Mediation and Conciliation Service)
shall not apply.
(2) STRIKES PERMITTED.—Paragraphs (3) and
(4) of section 7311 of title 5, United States Code
(prohibiting participation in a strike or an organiza-
tion asserting the right to strike), shall not apply
to employees of the Service.
(b) NEUTRALITY
IN UNION MATTERS.—The Na-
tional Health Board shall adopt as a matter of general
policy that governing boards at each level of the Service,
and employers acting as agents of these boards, agree to
determine employee preference on the subject of labor
union representation, and to determine which one if union
representation is preferred, by a card check procedure con-
ducted by a neutral third party in lieu of a formal election.
(c) COLLECTIVE BARGAINING.—
125
(1) IN GENERAL.—Collective-bargaining agree-
ments between area health boards and duly recog-
nized bargaining representatives of employees of the
Service may include procedures for resolution by the
parties of grievances and adverse actions arising
under the agreement, including procedures culmi-
nating in binding third-party arbitration.
(2) ALTERNATIVE PROCEDURES.—Area health
boards and duly recognized bargaining representa-
tives of employees of the Service may by mutual
agreement adopt procedures for the resolution by the
parties—
(A) of grievances and adverse actions aris-
ing under collective-bargaining agreements, and
(B) of disputes or impasses arising in the
negotiation of such agreements.
(d) CONFORMING AMENDMENT.—Section 3(e) of the
Labor-Management Reporting and Disclosure Act of 1959
(42 U.S.C. 402(e)) is amended by inserting ‘‘the United
States Health Service and’’ after ‘‘and includes’’.
SEC. 324. DEFENSE OF CERTAIN MALPRACTICE AND NEG-
LIGENCE SUITS.
(a) EXCLUSIVE REMEDY.—The remedy against the
United States provided by sections 1346(b) and 2672 of
title 28, United States Code, or by alternative benefits
126
provided by the United States where the availability of
such benefits precludes a remedy under section 1346(b)
of such title, for damage for personal injury, including
death, resulting from the performance of medical, surgical,
dental, or related functions, including the conduct of clin-
ical studies or investigations, by any employee of the Serv-
ice while acting within the scope of the employee’s employ-
ment, shall be exclusive of any other civil action or pro-
ceeding by reason of the same subject matter against the
employee (or the employee’s estate) whose act or omission
gave rise to the claim.
(b) DEFENSE.—The Attorney General shall defend
any civil action or proceeding brought in any court against
any person referred to in subsection (a) (or the person’s
estate) for any such damage or injury. Any such person
against whom such civil action or proceeding is brought
shall deliver within such time after date of service or
knowledge of service as determined by the Attorney Gen-
eral, all process served upon the person or an attested true
copy thereof to the person’s immediate superior or to
whomever was designated by the appropriate National
Health Board to receive such papers and such person shall
promptly furnish copies of the pleading and process there-
in to the United States attorney for the district embracing
the place wherein the proceeding is brought, to the Attor-
127
ney General, and to the appropriate National Health
Board.
(c) PROCEDURE.—
(1) REMOVAL FROM STATE COURTS.—Upon a
certification by the Attorney General that the de-
fendant was acting in the scope of employment at
the time of the incident out of which the suit arose,
any such civil action or proceeding commenced in a
State court shall be removed without bond at any
time before trial by the Attorney General to the dis-
trict court of the United States of the district and
division embracing the place wherein it is pending
and the proceeding deemed a tort action brought
against the United States under the provision of
title 28, United States Code, and all references
thereto.
(2) MOTIONS TO REMAND.—If a United States
district court determines on a hearing on a motion
to remand held before a trial on the merits that the
case so removed is one in which a remedy by suit
within the meaning of subsection (a) is not available
against the United States, the case shall be re-
manded to the State court.
(3) EFFECT
OF
ALTERNATIVE
REMEDIES.—
Where a remedy by suit within the meaning of sub-
128
section (a) is not available because of the availability
of a remedy through proceedings for compensation
or other benefits from the United States as provided
by any other law, the case shall be dismissed, but in
the event the running of any limitation of time for
commencing, or filing an application or claim in,
such proceedings for compensation or other benefits
shall be deemed to have been suspended during the
pendency of the civil action or proceeding under this
section.
(d) SETTLEMENT.—The Attorney General may com-
promise or settle any claim asserted in such civil action
or proceeding in the manner provided in section 2677 of
title 28, United States Code, and with the same effect.
(e) LIMITATION.—For purposes of this section, the
provisions of section 2680(h) of title 28, United States
Code, shall not apply to assault or battery arising out of
negligence in the performance of medical, surgical, dental,
or related functions, including the conduct of clinical stud-
ies or investigations.
(f) LIABILITY INSURANCE.—The appropriate Na-
tional Health Board may, to the extent it deems appro-
priate, hold harmless or provide liability insurance for any
employee of the Service for damage for personal injury,
including death, negligently caused by such employee while
129
acting within the scope of employment and as a result of
the performance of medical, surgical, dental, or related
functions, including the conduct of clinical studies or in-
vestigations, if the employee is assigned to a foreign coun-
try or detailed to a State or political subdivision thereof
or to a nonprofit institution, and if the circumstances are
such as are likely to preclude the remedies of third persons
against the United States described in section 2679(b) of
title 28, United States Code, for such damage or injury.
TITLE IV—OTHER FUNCTIONS
OF HEALTH BOARDS
Subtitle A—Advocacy, Grievance
Procedures, and Trusteeships
SEC. 401. ADVOCACY AND LEGAL SERVICES PROGRAM.
(a) ESTABLISHMENT
OF
PROGRAM.—Each area
health board shall establish a program of health advocacy
to ensure the full realization of the patient rights enumer-
ated in subtitle A of title II. Such a program shall
include—
(1) the employment of individuals having basic
legal knowledge and skills as health advocates;
(2) the presence of health advocates—
(A) in inpatient health care facilities at all
times; and
130
(B) in other health care facilities during
the provision of health care services;
(3) provision for health advocates to (A) in-
form, on an ongoing basis, users and health workers
of such patient rights and (B) report to the area
health board any infraction of such rights which is
not promptly corrected;
(4) provision for regular meetings between
health workers and health advocates, users, and any
user representatives to discuss ways of ensuring the
fulfillment of such rights through affirmative action
of such workers and the area health board; and
(5) appropriate action by the area health board
to ensure that infractions of such rights are prompt-
ly and sufficiently corrected.
(b) HEALTH RIGHTS LEGAL SERVICES.—
(1) ESTABLISHMENT OF PROGRAM.—The Na-
tional Health Board shall establish a health rights
legal services program and shall provide such pro-
gram with sufficient legal and administrative per-
sonnel, funding, and facilities (A) to ensure that
users and health workers receive, free of charge,
high quality legal services (including representation
in grievance proceedings commenced under section
402) for legal problems related to health rights and
131
health care services, and (B) to improve, through
litigation and other activities, the health care system
and expand the rights of users and health workers.
(2) SERVICES.—The health rights legal services
program shall provide directly, by contract with the
Legal Services Corporation, or by contract with
members of the private bar, for—
(A) establishment of a legal services office
in each region to provide representation (other
than representation provided under subpara-
graph (B)) of users, health workers, and vol-
untary associations having a demonstrated in-
terest in health care in proceedings and hear-
ings under sections 324 and 402; and
(B) establishment of legal services offices
in such communities and districts as are deter-
mined, in accordance with guidelines established
by the National Health Board, to have inad-
equate legal services to provide the legal serv-
ices described in paragraph (1)(A).
(3) USE OF CONTRACTS.—The National Health
Board may carry out the functions described in
paragraph (1)(B) directly, by contract, or otherwise.
SEC. 402. GRIEVANCE PROCEDURES AND TRUSTEESHIPS.
(a) GRIEVANCE PROCEEDINGS.—
132
(1) BEFORE
REGIONAL
BOARDS.—Each re-
gional and interim regional board shall provide, in
accordance with this section, that any user, health
worker, or any user association having a dem-
onstrated interest in health care may commence a
grievance proceeding before such board (or a person
or committee designated by such board) with respect
to an alleged violation of this Act by a district or
community board within its region. Each regional
and interim regional board may commence a griev-
ance proceeding before itself (or a person or com-
mittee designated by such board) with respect to an
alleged violation of this Act by a district or commu-
nity board within its region.
(2) BEFORE
NATIONAL
BOARD.—The appro-
priate National Health Board shall provide, in ac-
cordance with this section, that any user, health
worker, or any user association having a dem-
onstrated interest in health care may commence a
grievance proceeding before such Board (or a person
or committee designated by such Board) with re-
spect to an alleged violation of this Act by a regional
or interim regional board. The appropriate National
Health Board may commence a grievance proceeding
before itself (or a person or committee designated by
133
such Board) with respect to an alleged violation of
this Act by a regional or interim regional board.
(b) REVIEW.—
(1) BY
NATIONAL
BOARD.—The appropriate
National Health Board shall provide, subject to
paragraphs (2) and (3), for its review (or a review
by a person or committee designated by the Board),
by appeal to the Board by any party to a proceeding
described in subsection (a)(1) or on its own initia-
tive, of an adverse decision by a regional or interim
regional board in the proceeding.
(2) LIMITATION ONCE SUIT COMMENCED.—On
and after the date a suit with respect to an adverse
determination in a grievance proceeding or review
proceeding is filed under subsection (e), no review
proceeding respecting such proceeding may be com-
menced by appeal to the Board under paragraph (1),
and any such review proceeding which was com-
menced by appeal to the Board under such para-
graph before the date of filing of such suit and is
pending on such date shall promptly be discon-
tinued.
(3) TIME LIMIT.—No review of an adverse ad-
ministrative decision may be made by appeal or by
initiative under this subsection unless the appeal is
134
filed or notice of the initiative is published (as the
case may be) not later than 15 days after the publi-
cation of the decision.
(c) INVESTIGATION.—
(1) IN GENERAL.—Whenever a grievance pro-
ceeding is commenced under subsection (a), the enti-
ty before which the proceeding is held shall inves-
tigate the grievance.
(2) HEARING.—An entity before which a pro-
ceeding or review proceeding is commenced under
subsection (a) or (b)—
(A) shall conduct a full and open public
hearing on the grievance as part of such
proceeding—
(i) if the grievance is supported by a
petition signed by a minimal number of
residents (as defined in paragraph (4)); or
(ii) before the entity (or the body
which designated it) may set aside an elec-
tion or transfer any functions of a health
board under subsection (d); and
(B) may conduct such a hearing if the en-
tity determines that such hearing is in the pub-
lic interest.
135
(3) NOTICE.—The entity that conducts a hear-
ing under paragraph (2) shall provide for timely no-
tice to, and opportunity to be heard by, any party
with a direct interest in the grievance for which the
hearing is conducted.
(4) MINIMAL
NUMBER
OF
RESIDENTS
DE-
FINED.—As used in paragraph (1), the term ‘‘mini-
mal number of residents’’ means, with respect to a
grievance which concerns a health board which is—
(A) a community board, 100 individuals,
(B) a district board, 300 individuals, and
(C) a regional or interim regional board,
1,000 individuals,
who are 18 years of age or older and who reside in
the area served by the board.
(d) ACTIONS UPON GRIEVANCES.—
(1) ELECTION GRIEVANCES.—With respect to a
grievance proceeding begun under subsection (a) re-
lating to the conduct of an election of a community
board, if the entity before which such proceeding is
commenced under such subsection, or is reviewed
under subsection (b), determines that the election—
(A) was not conducted substantially in
compliance with this Act, or
136
(B) has revealed the systematic failure of
the user members of such community board to
approximate the population of the community
by race, sex, language, and income level,
the entity shall set aside the election and, unless
such determination is reviewed under subsection (b),
the entity shall require that another election for
members of the community board be conducted, in
accordance with this Act, not later than 60 days
after the date of such determination. If such election
is conducted because of a determination under sub-
paragraph (B), the election shall be conducted (and
subsequent elections may be conducted) in such a
manner, including the use of geographic or other
subdivisions for electoral purposes, as will facilitate
the representation of significant elements of the pop-
ulation of a community by race, sex, language, and
income level.
(2) OTHER
GRIEVANCES.—With respect to a
grievance proceeding begun under subsection (a) re-
lating to a grievance other than the conduct of an
election of a community board, if the entity before
which such proceeding is commenced under such
subsection, or is reviewed under subsection (b), de-
termines that the grievance represents—
137
(A) a failure by a health board to comply
substantially and materially with this Act, the
entity shall require that a new election or ap-
pointment, in accordance with this Act, of mem-
bers of the health board be conducted or made
within 60 days of the date of such determina-
tion; or
(B) a failure by a health board to comply,
but not substantially and materially, with this
Act, the entity may require that a new election
or appointment, in accordance with this Act, of
members of the health board be conducted or
made if such failure is not corrected within a
reasonable period of time (specified by the enti-
ty) of the date of such determination.
(3) TRANSFER OF FUNCTIONS.—
(A) TO REGIONAL BOARDS.—If an entity
determines under paragraph (1) or (2) that a
community or district board has failed to com-
ply with this Act, the entity shall transfer to
the regional (or interim regional) board for
such community or district such functions of
the community or district board as it deter-
mines necessary to carry out this Act until a
138
new election or appointment is conducted or
made.
(B) TO NATIONAL BOARD.—If an entity
determines under paragraph (2) that a regional
or interim regional board has failed to comply
with this Act, the entity shall transfer to the
appropriate National Health Board such func-
tions of the regional or interim regional board
as it determines necessary to carry out this Act
until a new regional or interim regional board
is appointed.
(C) 
TRANSITIONAL
AUTHORITY.—If 
a
health board is transferred the functions of an-
other health board under this paragraph, until
a new election or appointment of the other
health board has been certified—
(i) the health board shall have the
powers of the other health board to con-
duct such functions;
(ii) the health board may appoint a
trustee (or trustee committee) to have such
powers and carry out such functions; and
(iii) any expenses that are certified by
the health board (or by the trustee or
trustee committee appointed by it) as hav-
139
ing been incurred by it in discharging the
functions transferred to it under this para-
graph shall be paid from funds allocated to
the other health board.
(e) RIGHT TO SUE.—Any party to a grievance pro-
ceeding or review proceeding commenced under this sec-
tion may bring suit in the United States district court for
the judicial district in which such proceeding, or review
proceeding, was brought, for the review of an adverse de-
termination in such proceeding or review proceeding. Such
court shall affirm such determination unless it finds that
such determination is not supported by substantial evi-
dence or is arbitrary and capricious.
Subtitle B—Occupational Safety
and Health Programs
SEC. 411. FUNCTIONS OF THE NATIONAL HEALTH BOARD.
(a) OVERSIGHT AUTHORITY.—On and after the effec-
tive date of health services, the National Health Board
shall oversee occupational safety and health programs con-
ducted at the regional level, and shall participate in the
establishment and administration of occupational safety
and health standards under the Occupational Safety and
Health Act of 1970.
(b) SEEKING ADVICE.—In its participation in the es-
tablishment and administration of occupational safety and
140
health standards under the Occupational Safety and
Health Act of 1970, the National Health Board shall seek
the advice and comments of regional occupational safety
and health action councils established under section 413.
(c) CONFORMING AMENDMENTS.—
(1) IN GENERAL.—To provide for participation
of the National Health Board in the establishment
and administration of occupational safety and health
standards, the Occupational Safety and Health Act
of 1970 (29 U.S.C. 651 et seq.) is amended—
(A) by adding at the end of section 3 the
following new paragraph:
‘‘(15) The term ‘National Health Board’ means
the National Health Board of the United States
Health Services.’’;
(B) by striking ‘‘Secretary of Health and
Human Services’’ each place it appears (other
than in section 22(b)) and inserting ‘‘National
Health Board’’;
(C) by inserting ‘‘shall request the Na-
tional Health Board and’’ in the first sentence
of section 6(b)(1) before ‘‘may request’’;
(D) by inserting ‘‘the Board and’’ in the
second sentence of section 6(b)(1) after ‘‘The
Secretary shall provide’’;
141
(E) by striking ‘‘An’’ in the third sentence
of section 6(b)(1) and inserting ‘‘The Board
and an’’;
(F) by striking ‘‘its’’ each place it appears
in the third sentence of section 6(b)(1) and in-
serting ‘‘their’’;
(G) by inserting ‘‘after consultation with
the National Health Board and’’ in the fourth
sentence of section 6(b)(6)(A) after ‘‘may be
granted only’’;
(H) by inserting ‘‘after consultation with
the National Health Board and’’ in the third
sentence of section 6(d) before ‘‘after oppor-
tunity for’’;
(I) by striking ‘‘The Secretary’’ and all
that follows through ‘‘shall each’’ in section
8(g)(2) and inserting ‘‘The Secretary shall’’;
(J) by striking ‘‘their’’ in section 8(g)(2)
and inserting ‘‘his’’;
(K) by inserting ‘‘after consultation with
the National Health Board and’’ in section 16
before ‘‘after notice and opportunity’’;
(L) by inserting ‘‘(after consultation with
the National Health Board)’’ in section 18(c)
after ‘‘in his judgment’’;
142
(M) by inserting ‘‘and the National Health
Board’’ in section 19(d) after ‘‘Secretary’’ each
place it appears; and
(N) by striking the first sentence of para-
graph (5) of section 20(a).
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall take effect on the effective
date of health services.
(f) GUIDELINES.—The National Health Board shall
establish guidelines—
(1) for its participation in the establishment
and administration of occupational safety and health
standards under the Occupational Safety and Health
Act of 1970;
(2) for the election of community occupational
safety and health action councils under section 412;
(3) for the establishment of regional occupa-
tional safety and health programs under section 413;
(4) for the establishment and operation of
workplace health facilities under section 414; and
(5) for the provision of assistance by regional
and community boards to regional and community
occupational safety and health councils, respectively,
and to workplace safety and health committees es-
tablished under section 415.
143
SEC. 
412. 
COMMUNITY 
OCCUPATIONAL 
SAFETY 
AND
HEALTH ACTIVITIES.
(a) DESCRIPTION OF ACTIVITIES.—
(1) COOPERATION WITH REGIONAL BOARD.—
Each community board shall cooperate with the ap-
propriate regional board in the establishment and
implementation of an occupational safety and health
program for its region.
(2) ESTABLISHMENT OF COMMUNITY OCCUPA-
TIONAL
SAFETY
AND
HEALTH
ACTION
COUNCIL
(COSHAC).—Each community board shall provide for
the organization and operation (including staff and
support) in its community of a community occupa-
tional safety and health action council (hereinafter
in this subtitle referred to as a ‘‘COSHAC’’) in ac-
cordance with this section.
(b) MEMBERS OF COSHAC.—The members of a
COSHAC shall be elected by individuals employed in the
community as follows:
(1) Employees of each workplace in the commu-
nity which has 500 or more employees shall be enti-
tled to elect one member for each 500 such employ-
ees in such workplace.
(2) Employees of workplaces in the community
which have fewer than 500 employees shall be enti-
tled to vote in community-wide elections for a num-
144
ber of members equal to (A) the total number of
employees in such workplaces divided by 500, (B)
rounded (if necessary) to the next highest whole
number.
The elections of COSHAC members shall be conducted by
the community board for such COSHAC under guidelines
established by the National Board.
(c) DUTIES OF COSHAC.—Each COSHAC shall—
(1) appoint one individual to serve, at its pleas-
ure, as a member of the community board for such
COSHAC;
(2) appoint one individual to serve, at its pleas-
ure, as a member of the regional occupational safety
and health action council for its region;
(3) advise the community board on, and over-
see, occupational safety and health programs in the
community;
(4) promote and assist in the establishment of
workplace occupational safety and health committees
in workplaces in the community, and advise and fa-
cilitate such committees’ actions relating to safety
and health hazards in workplaces in the community;
and
145
(5) assist employees in determining methods of,
and requirements for, inspections of workplaces in
the community for safety and health hazards.
SEC. 413. REGIONAL OCCUPATIONAL SAFETY AND HEALTH
PROGRAMS.
(a) REGIONAL PROGRAMS.—
(1) ESTABLISHMENT.—Each regional board
shall establish an occupational health and safety
program for its region in accordance with this sub-
section and under guidelines established by the Na-
tional Health Board.
(2) USE
OF
COMMUNITY
FACILITIES.—A re-
gional occupational health and safety program shall,
to the maximum extent feasible, use the facilities
and resources of community boards in the region
and shall include—
(A) training programs to enhance the abil-
ity of employees in the region to monitor safety
and health conditions in their workplaces and to
assist safety and health inspectors in the con-
duct of workplace inspections;
(B) 
facilitating 
communication 
among
workers employed in similar industries in the
region and the Nation with respect to occupa-
146
tional health and safety hazards they face in
common;
(C) baseline and periodic biologic screening
of employees in the region;
(D) development and maintenance of envi-
ronmental monitoring programs to identify and
isolate hazardous workplaces and work areas in
the region;
(E) the analysis of employment-related in-
juries and illnesses occurring in the region; and
(F) staff and support for the operation of
the regional occupational safety and health ac-
tion council (hereinafter in this subtitle referred
to as the ‘‘ROSHAC’’) established in the region
under this section.
(b) DUTIES OF REGIONAL OCCUPATIONAL SAFETY
AND HEALTH ACTION COUNCILS
(ROSHACS).—Each
ROSHAC shall—
(1) appoint one individual to serve, at its pleas-
ure, as a member of the regional board for such
ROSHAC;
(2) advise the regional board on, and oversee,
occupational safety and health programs in the re-
gion; and
147
(3) advise the National Health Board on the es-
tablishment and administration of occupational safe-
ty and health standards under the Occupational
Safety and Health Act of 1970.
SEC. 414. WORKPLACE HEALTH FACILITIES.
(a) ESTABLISHMENT.—Each Community Health
Board shall establish worksite health facilities, distributed
to make available occupational and emergency health care
services to individuals employed in the workplace in ac-
cordance with this section and guidelines and standards
for such facilities established by the National Health
Board. Such facilities shall be maintained by each em-
ployer where the facility is located, or by the group of em-
ployers covered by a facility if the Community Health
Board determines that a shared site is optimal.
(b) APPLICATION OF GUIDELINES.—Each workplace
health facility established pursuant to subsection (a) shall,
taking into account guidelines established by the National
Health Board—
(1) be organized in a manner so as to provide
an appropriate number of appropriately skilled
health workers to meet occupational and emergency
health care needs of employees in the workplace; and
(2) be operated by the community board for the
community in which the workplace is predominantly
148
located, or, where such board deems appropriate, by
the employer, with the cost in either case borne by
the employer in each workplace.
SEC. 415. EMPLOYEE RIGHTS RELATING TO OCCUPATIONAL
SAFETY AND HEALTH.
(a) WORKPLACE COMMITTEES.—
(1) 
ESTABLISHMENT.—Employees 
in 
each
workplace having 25 or more employees shall have
the right to establish workplace occupational safety
and health committees (hereinafter in this sub-
section referred to as ‘‘committees’’) with members
of their choosing.
(2) MEMBERSHIP.—Members of committees
(composed of the greater of 3 members or one mem-
ber for each 100 employees in the workplace) shall,
without any loss of pay or other job rights—
(A) be permitted to spend eight hours of
each month inspecting their workplace and con-
ducting such other functions relating to occupa-
tional safety and health as are determined by
the employees in the workplace; and
(B) be permitted to accompany any safety
and health inspectors during inspections of the
workplace.
149
(b) SAFETY-RELATED RIGHTS.—Employees in each
workplace shall have the right, without any loss of pay
or other job rights—
(1) to monitor safety and health conditions in
their workplace whenever they reasonably deem it
necessary and with whatever reasonable scientific in-
struments and expert assistance they choose; and
(2) to remove themselves from the site of any
hazard to their safety or health until an authorized
inspector has certified that the hazard has been
eliminated.
(c) SAFE WORKPLACES.—Employers shall adopt all
feasible engineering measures that will minimize occupa-
tional safety and health hazards in the workplace. Where
such measures are not adequate to protect employees from
such hazards, employers shall furnish their employees
with, or reimburse their employees for the reasonable cost
of, equipment and clothing needed to protect an employee
from any residual occupational safety and health hazards
in the workplace.
(d) RIGHT TO INSPECT MEDICAL RECORDS.—Em-
ployees or their duly chosen representatives shall have the
right to inspect all medical records maintained by their
employers on the condition of their health, and shall have
150
the right to be assisted during such inspections by persons
of their choosing.
(e) COPIES OF REPORTS.—Employers shall provide
their employees with copies of all reports, studies, and
data concerning conditions affecting the health and safety
of employees within their workplaces, with annual reports
on the morbidity and mortality experience of present and
former employees, and with timely notification of the pres-
ence within the workplace of any materials, agents, or con-
ditions which may have a deleterious effect on the safety
and health of their employees, along with relevant infor-
mation on hazards and precautions, symptoms, remedies,
and antidotes.
(f) RIGHT TO NEGOTIATE STANDARDS.—Employees
shall have the right to seek, through collective bargaining,
occupational safety and health standards, including stand-
ards relating to physical and mental stress and speed of
work, more restrictive than such standards established
under the Occupational Safety and Health Act of 1970.
SEC. 416. DEFINITIONS.
(a) WORKPLACE.—For purposes of this subtitle, the
term ‘‘workplace’’ means the regular location where work
is performed by one or more employees of an employer.
(b) EMPLOYER; EMPLOYEE.—For the purposes of
sections 414 and 415, the terms ‘‘employer’’ and ‘‘em-
151
ployee’’ have the same meanings those terms have in sec-
tion 3 of the Occupational Safety and Health Act of 1970
(42 U.S.C. 653).
Subtitle 
C—Health 
and 
Health
Care Delivery Research, Quality
Assurance, and Health Equity
SEC. 421. PRINCIPLES AND GUIDELINES FOR RESEARCH.
(a) CONDUCT.—On and after the effective date of
health services, the Service shall conduct a program of re-
search concerning health and health care delivery. On and
after 2 years after such date, such research program shall
conform to the following principles:
(1) The research shall, to the maximum extent
possible, be performed under the direction of, and in
association with, community, district, and regional
boards.
(2) No research shall be conducted within, or
using the resources of, an area health facility until
it has been reviewed and approved by the area
health board responsible for such facility.
(3) Priority shall be given in health research to
the prevention and correction of the leading causes
of illness and death, particularly environmental, oc-
cupational, nutritional, social, and economic causes.
152
(4) Priority shall be given in health care deliv-
ery research to improvement of the effectiveness and
efficiency of ambulatory and primary health care de-
livery, including research on alternative systems of
health care delivery and alternative conceptions of
health and health care.
(5) The National Health Board shall encourage
and support the conduct of clinical trials that may
improve the health of the public. Any clinical trial
conducted with the intention of evaluating new pre-
ventive, diagnostic, or therapeutic methods or agents
shall be conducted only in accordance with estab-
lished ethical procedures that protect subjects from
undue harm. If benefit becomes apparent, by sci-
entific consensus, before the scheduled conclusion of
any clinical trial, such trial shall nevertheless be ter-
minated, and the benefit made available to trial par-
ticipants and the public at large.
(6) No research shall be conducted on a human
subject without the subject’s informed written con-
sent.
(7) No research shall be conducted on a human
subject while the subject is involuntarily confined to
an institution.
153
(8) Each health board, in planning and con-
ducting research under the program, shall cooperate
with appropriate officials conducting related re-
search in the Federal Government and agencies and
departments of State, territorial, and local govern-
ments.
(9) The results of research shall be dissemi-
nated to the public and to area health boards in a
manner that will most readily permit the use of such
results to improve the health of users and the deliv-
ery of health care services.
(b) GUIDELINES.—The National Health Board shall
establish guidelines for the conduct of research in con-
formance with the principles described in subsection (a).
SEC. 422. ESTABLISHMENT OF INSTITUTES.
On the effective date of health services, the National
Institutes of Health (established under title IV of the Pub-
lic Health Service Act) are transferred to the National
Health Board. In addition, the National Health Board
shall establish the following institutes:
(1) NATIONAL INSTITUTE OF EPIDEMIOLOGY.—
A National Institute of Epidemiology, which shall—
(A) gather and analyze disease-related sta-
tistics collected by the Service;
154
(B) plan, conduct, support, and assist in
epidemiologic research conducted by the Serv-
ice;
(C) conduct and support research on epi-
demiologic methodology and experimental epide-
miology;
(D) establish and maintain an early warn-
ing system for the detection of new diseases
and epidemics; and
(E) assist in the formulation of policies to
eliminate or reduce the causes of illness and in-
jury and to prevent and curtail epidemics of
these conditions.
(2) NATIONAL
INSTITUTE
OF
EVALUATIVE
CLINICAL RESEARCH.—A National Institute of Eval-
uative Clinical Research, which shall—
(A) create a uniform electronic data base
for research on quality improvement in clinical
care and the organization and delivery of serv-
ices, and for research on outcomes of care;
(B) assess and analyze evidence on newly-
discovered or proposed preventive, diagnostic,
and therapeutic methods and agents, including
new technologies, and assist the National
Health Board, in cooperation with other bodies,
156
mined by the most recent evidence, and assist
the National Health Board, in cooperation with
other bodies, in establishing guidelines to im-
prove clinical practice, including clinical deci-
sion criteria per section 221(f);
(iii): regularly monitor and report to the
National Health Board for further action the
extent of inappropriate care, including under-
service and overservice, and its consequences;
(iv) develop additional methods of quality
improvement for implementation by the Na-
tional Health Board and other entities, includ-
ing systematic review of patterns of practice
that compromise the quality of care and rec-
ommendations to redress such practices, edu-
cation for health care workers to improve the
quality of care, and guidelines for the optimal
organization of health services and the use of
tertiary care facilities;
(G) administer the periodic convening of
the U.S. Preventive Health Services Task
Force, which shall recommend to the National
Board a schedule for preventive health services
based on age and sex, which schedule shall re-
flect the most recent medical evidence; and
157
(H) provide education for users on clinical
effectiveness guidelines and the most effective
preventive, diagnostic, and treatment practices.
(3) NATIONAL
INSTITUTE
OF
HEALTH
CARE
SERVICES.—A National Institute of Health Care
Services, which shall—
(A) analyze data and statistics on the
health care resources and needs of the Nation
and on the quality of present services;
(B) conduct comparative studies of health
care services in the various regions of the Na-
tion, and make recommendations for the im-
provement of health care services in areas with
inferior quality of health care services;
(C) plan and conduct research on alter-
native methods of health care delivery, on the
functions, tasks, performance and work rela-
tionships of various kinds and categories of
health workers, on patterns of organization of
health care, and on the effectiveness and bene-
fits of health care in relation to costs; and
(D) assist the National Health Board in
formulating national policies to improve the
quality of health care services.
158
(4) NATIONAL INSTITUTE OF PHARMACY AND
MEDICAL SUPPLY.—A National Institute of Phar-
macy and Medical Supply, which shall—
(A) recommend to the National Health
Board standards regarding the quality, dis-
tribution, and price of all drugs, therapeutic de-
vices, appliances and equipment to be used by
the Service;
(B) certify drugs, therapeutic devices, ap-
pliances, and equipment for use in the health
facilities of the Service, and for furnishing to
users of such health facilities;
(C) assist the National Health Board in
issuing a National Pharmacy and Medical Sup-
ply Formulary; and
(D) conduct a comprehensive program of
pharmaceutical and medical supply research
and utilization education using, to the max-
imum extent possible, regional facilities oper-
ated in association with the respective regional
health boards.
(5) NATIONAL
INSTITUTE
OF
SOCIOLOGY
OF
HEALTH AND HEALTH CARE.—A National Institute
of Sociology of Health and Health Care, which
shall—
159
(A) conduct ongoing analyses of the basic
epistemological assumptions of health and
health care;
(B) assess critically the effects of scientific
medicine and of divisions in institutional and
technical skills in health care;
(C) evaluate the effects of health care
measures and policies upon population groups
and subgroups in the Nation;
(D) identify and analyze the social, eco-
nomic, occupational, distributional, and environ-
mental factors in modern society affecting
health and well-being;
(E) analyze alternative, holistic approaches
to the human body, health, and causality of ill
health and the lack of social and psychological
well-being; and
(F) assist the National Health Board in
formulating national policies relating to the pro-
motion of health and the provision of health
care.
160
Subtitle D—Health Planning, Dis-
tribution of Drugs and Other
Medical Supplies, and Miscella-
neous Functions
SEC. 431. HEALTH PLANNING AND BUDGETING.
(a) IN GENERAL.—Each area health board shall,
under guidelines established by the National Health
Board, collect data on the supply of and demand for health
workers in facilities under its supervision, and on the de-
livery of health care and supplemental services in health
care facilities under its supervision, shall evaluate such
data in relation to the health care needs of their respective
area, and shall transmit such data and evaluation—
(1) to its respective regional board, in the case
of a district or community board, and
(2) to the National Health Board, in the case
of a regional board,
and shall make available such data and evaluations to resi-
dents of its area.
(b) COORDINATION.—Each regional board shall co-
ordinate the planning and administration of the delivery
of health care services, health worker education, and
health research in its region, and shall facilitate the plan-
ning and administration of such programs by district and
community boards in its region.
161
(c) PLANS.—The National Health Board shall formu-
late a 1-year and 5-year national health plan and budget,
taking into account the area plans and budgets prepared
in accordance with section 522, to provide guidance and
direction to area health boards.
SEC. 432. DISTRIBUTION OF DRUGS AND OTHER MEDICAL
SUPPLIES.
(a) NATIONAL FORMULARY.—
(1) 
PUBLICATION.—The 
National 
Health
Board, after consultation with the regional boards,
shall, not later than the effective date of health serv-
ices, publish and disseminate to area health boards
a National Pharmacy and Medical Supply For-
mulary (in this section referred to as the ‘‘For-
mulary’’).
(2) CONTENTS.—The Formulary shall contain a
listing of drugs, therapeutic devices, appliances,
equipment, and other medical supplies (including
eyeglasses, other visual aids, hearing aids, and pros-
thetic devices) (in this section referred to as ‘‘drugs
and other medical supplies’’). For each item on such
listing the Formulary shall contain (A) the stand-
ards of quality for the production of such item, (B)
the medical conditions for which the item is certified
as effective for purposes of the provision of health
162
care services under this Act, and (C) such other in-
formation on such item as the National Health
Board determines to be appropriate for the effective
and efficient delivery of health care services under
this Act.
(3) UPDATING.—The National Health Board
shall, at regular intervals, update the contents of the
Formulary and publish a price list for items listed
in the Formulary, which prices shall reflect the ac-
tual costs of manufacture.
(b) DRUG PURCHASE PROGRAMS.—
(1) IN GENERAL.—Each regional board shall
establish a program, in accordance with this sub-
section and under guidelines established by the Na-
tional Health Board, for the purchase and distribu-
tion of drugs and other medical supplies for use in
health care facilities established by such board or by
a community or district board within its region.
(2) PRICING.—Such program shall provide for
the purchase of each drug or other medical supply
item only (A) following competitive bidding on such
item or (B) based on the price listed for such item
in the price list published under subsection (a)(3).
(3) GENERIC
DISTRIBUTION.—Such program
shall provide for the distribution of drugs (and their
163
dispensing by community and district boards in its
region) under their generic names.
(4) GENERIC NAMES DEFINED.—For purposes
of paragraph (3), the term ‘‘generic names’’ means
the established names, as defined in section
502(e)(2) of the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 352(e)(2)).
(c) AUTHORITY TO MANUFACTURE.—The National
Health Board is authorized to establish and operate drug
and medical supply manufacturing facilities, if it deter-
mines that such operation will result in reduced expendi-
tures by the Service.
SEC. 433. MISCELLANEOUS FUNCTIONS OF THE NATIONAL
HEALTH BOARD.
SEC. 433. (a) ANNUAL REPORT.—The appropriate
National Health Board shall publish, not later than De-
cember 31 of each year, a report presenting and evalu-
ating operations of the Service during the fiscal year end-
ing in such year and surveying the future health needs
of the Nation and plans the Board has for the Service
to meet such needs.
(b) DISSEMINATION.—The National Health Board
shall, not later than the effective date of health services,
prepare and disseminate to area health boards, for use by
users, information about health and health services
164
deemed essential to ensure users’ active and informed par-
ticipation in the health care system, including information
that is culturally appropriate for each area’s principal cul-
tural and ethnic groupings, a comprehensive dictionary of
terms used in health care records and services maintained
or provided by the Service. Such dictionary shall explain
terms related to symptoms, signs, diagnoses, etiologic
agents and conditions, diagnostic procedures, and the
treatment and prevention of, and rehabilitation following,
illnesses, and shall include extensive citations of lay and
professional sources which a user might consult for addi-
tional information on such terms.
TITLE V—FINANCING OF THE
SERVICE
Subtitle A—Health Service Taxes
SEC. 501. INDIVIDUAL AND CORPORATE INCOME TAXES.
(a) HEALTH SERVICE TAXES.—
(1) IN GENERAL.—Subchapter A of chapter 1
of the Internal Revenue Code of 1986 (relating to
normal taxes and surtaxes) is amended by adding at
the end the following new part:
‘‘PART VIII—HEALTH SERVICE TAXES
‘‘Sec. 59B. Tax imposed.
165
‘‘SEC. 59B. TAX IMPOSED.
‘‘(a) INDIVIDUALS, ESTATES, AND TRUSTS.—In ad-
dition to other taxes, there is hereby imposed for each tax-
able year on the taxable income of every individual and
of every estate and trust taxable under section 1(d), a tax
in an amount equal to 10 percent of the total tax imposed
by section 1 for such taxable year.
‘‘(b) CORPORATION.—In addition to the other taxes,
there is hereby imposed for each taxable year on the tax-
able income of every corporation, a tax in an amount equal
to 90 percent of the total amount of the normal tax and
surtax imposed by section 11 for such taxable year.’’
(2) CLERICAL
AMENDMENT.—The table of
parts of such subchapter A is amended by adding
after the item relating to part VII the following new
item:
‘‘Part VIII. Health service taxes.’’.
(c) EFFECTIVE DATE.—The amendments made in
this section shall apply to taxable years beginning on or
after the effective date of health services.
SEC. 502. OTHER CHANGES IN THE INTERNAL REVENUE
CODE OF 1986.
(a) DENIAL OF EXCLUSION FROM GROSS INCOME
FOR AMOUNTS PAID BY THIRD PARTIES FOR MEDICAL
CARE.—Section 105 of the Internal Revenue Code of 1986
166
(relating to amounts received under accident and health
plans) is amended by striking subsection (b).
(b) DENIAL OF EXCLUSION FROM GROSS INCOME OF
CERTAIN
CONTRIBUTIONS
BY
THE
EMPLOYER
TO
HEALTH PLANS.—Subsection (a) of section 106 of such
Code (relating to contributions by employer to accident
and health plans) is amended to read as follows:
‘‘(a) GENERAL RULE.—Except as otherwise provided
in this section, gross income does not include contributions
by the employer to accident or health plans for compensa-
tion (through insurance or otherwise) to his employees for
personal injuries or sickness to the extent that such con-
tributions do not provide for health care and supplemental
services available to such employees under the Josephine
Butler United States Health Service Act.’’
(c) DENIAL OF DEDUCTION OF HEALTH CARE EX-
PENSES AS TRADE OR BUSINESS EXPENSES.—Section
162 of such Code (relating to trade or business expenses)
is amended by redesignating subsection (p) as subsection
(q) and by adding after subsection (o) the following new
subsection:
‘‘(p) PAYMENTS FOR HEALTH CARE.—No deduction
shall be allowed under subsection (a) for any amount paid
for health care services (other than any amount of tax im-
posed by section 59B and paid by the employer on behalf
167
of his employees) which an individual was eligible to re-
ceive under title II of the Josephine Butler United States
Health Service Act.’’.
(d) DENIAL OF DEDUCTION FOR CONTRIBUTIONS TO
CERTAIN MEDICAL AND HOSPITAL FACILITIES.—
(1) Paragraph (2) of section 170(c) of such
Code (relating to charitable, etc., contributions and
gifts) is amended by inserting ‘‘(other than an orga-
nization described in subsection (b)(1)(A)(iii))’’ after
‘‘(2) A corporation, trust, or community chest, fund,
or foundation’’.
(2) Subsection (e) of section 501 of such Code
(relating to cooperative hospital service organiza-
tions) is amended by striking the last sentence.
(e) DENIAL OF DEDUCTION FOR MEDICAL, DENTAL,
ETC., EXPENSES.—
(1) Section 213 of such Code (relating to med-
ical, dental, etc., expenses) is repealed.
(2) The table of sections of part VII of sub-
chapter B of chapter 1 of such Code is amended by
striking the item relating to section 213.
(f) HOSPITAL INSURANCE TAX.—
(1) Subsection (b) of section 1401 of such Code
(relating to rate of tax on self-employment income)
is repealed.
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(A) Subsection (b) of section 3101 of such
Code (relating to rate of tax on employees
under the Federal Insurance Contributions Act)
is repealed.
(B) Section 3201(a) of such Code (relating
to rate of tax imposed on employees under the
Railroad Retirement Tax Act) is amended by
striking ‘‘subsections (a) and (b)’’ and inserting
‘‘subsection (a)’’.
(C) Section 3211(a)(1) of such Code (re-
lating to rate of tax on employee representatives
under the Railroad Retirement Tax Act) is
amended by striking ‘‘subsections (a) and (b)’’
and inserting ‘‘subsection (a)’’.
(D) Subsection (e) of section 6051 of such
Code (relating to railroad employees) is re-
pealed.
(g) EFFECTIVE DATE.—The amendments made by
this section shall apply to taxable years beginning on or
after the effective date of health services.
SEC. 503. EXISTING EMPLOYER-EMPLOYEE HEALTH BEN-
EFIT PLANS.
No contractual or other nonstatutory obligation of
any employer to pay for or provide any health care and
supplemental service to his present and former employees
169
and their dependents and survivors, or to any of such per-
sons, shall apply on and after the effective date of health
services to the extent such individuals are eligible to re-
ceive such health care and supplemental services under
this Act.
SEC. 504. WORKERS COMPENSATION PROGRAMS.
No workers compensation program, whether estab-
lished pursuant to Federal or State law or private initia-
tive, shall pay for or provide any health care and supple-
mental services on and after the effective date of health
services, to the extent such health care and supplemental
services are available under this Act.
Subtitle B—Health Service Trust
Fund
SEC. 511. ESTABLISHMENT OF HEALTH SERVICE TRUST
FUND.
(a) ESTABLISHMENT.—There is hereby created on
the books of the Treasury of the United States a trust
fund to be known as the Health Service Trust Fund (in
this title referred to as the ‘‘Trust Fund’’). The Trust
Fund shall consist of such gifts and bequests as may be
made to the Service and such amounts as may be depos-
ited in, or appropriated to, such fund as provided in this
subtitle.
170
(b) APPROPRIATION.—There is hereby appropriated
to the Trust Fund for each fiscal year beginning in the
fiscal year in which the effective date of health services
(as defined in title VI) falls, and for each fiscal year there-
after, out of any moneys in the Treasury not otherwise
appropriated, an amount equal to 100 percent of expected
net receipts from the taxes imposed by sections 59B and
3111(b) of the Internal Revenue Code of 1986 (as esti-
mated by the Secretary of the Treasury). The amount ap-
propriated by the preceding sentence shall be transferred
from time to time from the general fund in the Treasury
to the Trust Fund in such smaller amounts to be deter-
mined on the basis of estimates by the Secretary of the
Treasury of the receipts specified in the preceding sen-
tence; and proper adjustments shall be made in the
amounts subsequently transferred to the extent prior esti-
mates were in excess of or were less than the receipts spec-
ified in such sentence.
SEC. 512. TRANSFER OF FUNDS TO THE HEALTH SERVICE
TRUST FUND.
(a) OF MEDICARE TRUST FUNDS.—On the effective
date of health services, there are transferred to the Trust
Fund all of the assets and liabilities of the Federal Hos-
pital Insurance Trust Fund and the Federal Supple-
mentary Medical Insurance Trust Fund.
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(b) ADDITIONAL AMOUNTS.—In addition to the sums
appropriated by section 511(b), there is appropriated to
the Trust Fund for each fiscal year, out of any moneys
in the Treasury not otherwise appropriated, a govern-
mental contribution equal to 40 percent of the sums ap-
propriated by section 511(b) for such fiscal year. There
shall be deposited in the Trust Fund all recoveries of over-
payments, and all receipts under loans or other agree-
ments entered into, under this Act.
SEC. 513. ADMINISTRATION OF HEALTH SERVICE TRUST
FUND.
(a) BOARD
OF TRUSTEES.—With respect to the
Trust Fund, there is hereby created a body to be known
as the Board of Trustees of the Trust Fund (in this sec-
tion referred to as the ‘‘Board of Trustees’’) composed of
the Secretary of the Treasury, the Secretary of Health and
Human Services, and the Chairperson of the National
Health Board, all ex officio. The Secretary of the Treasury
shall be the Managing Trustee of the Board of Trustees
(in this section referred to as the ‘‘Managing Trustee’’).
The Chairperson of the National Health Board shall serve
as the Secretary of the Board of Trustees. The Board of
Trustees shall meet not less frequently than once each cal-
endar year. It shall be the duty of the Board of Trustees
to—
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(1) hold the Trust Fund;
(2) report to the Congress not later than the
first day of April of each year on the operation and
status of the Trust Fund during the preceding fiscal
year and on its expected operation and status during
the current fiscal year and the next 2 fiscal years;
(3) report immediately to the Congress when-
ever the Board is of the opinion that the amount of
the Trust Fund is unduly small; and
(4) review the general policies followed in man-
aging the Trust Fund, and recommend changes in
such policies, including necessary changes in the
provisions of law which govern the way in which the
Trust Fund is to be managed.
The report provided for in paragraph (2) shall include a
statement of the assets of, and the disbursements made
from, the Trust Fund during the preceding fiscal year,
an estimate of the expected income to, and disbursements
to be made from, the Trust Fund during the current fiscal
year and each of the next 2 fiscal years, and a statement
of the actuarial status of the Trust Fund. Such report
shall be printed as a House document of the session of
the Congress to which the report is made.
(b) INVESTMENT.—It shall be the duty of the Man-
aging Trustee to invest such portion of the Trust Fund
173
as is not, in his judgment, required to meet current with-
drawals. Such investments may be made only in interest-
bearing obligations of the United States or in obligations
guaranteed as to both principal and interest by the United
States. For such purpose such obligations may be acquired
(1) on original issue at the issue price, or (2) by purchase
of outstanding obligations at the market price. The pur-
poses for which obligations of the United States may be
issued under the Second Liberty Bond Act, as amended,
are hereby extended to authorize the issuance at par of
public-debt obligations for purchase by the Trust Fund.
(c) ISSUANCE OF OBLIGATIONS.—Any obligations ac-
quired by the Trust Fund (except public-debt obligations
issued exclusively to the Trust Fund) may be sold by the
Managing Trustee at the market price, and such public-
debt obligations may be redeemed at par plus accrued in-
terest.
(d) PAYMENT OF INTEREST.—The interest on, and
the proceeds from the sale or redemption of, any obliga-
tions held in the Trust Fund shall be credited to and form
a part of the Trust Fund.
(e) PAYMENTS.—The Managing Trustee shall pay
from time to time from the Trust Fund such amounts as
the National Health Board certifies are necessary to carry
out this Act.
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Subtitle C—Preparation of Plans
and Budgets
SEC. 521. DETERMINATION OF FUND AVAILABILITY.
(a) MAXIMUM FUNDS.—
(1) FIXING.—The National Health Board shall,
not later than January 1 of each year, initially fix
the maximum amount of funds which may (except as
provided in subsection (c)) be obligated during the
fiscal year beginning on October 1 of such year for
expenditure from the Trust Fund.
(2) LIMITATION.—Such amount shall not ex-
ceed for a fiscal year the lesser of—
(A) 140 percent of the expected net re-
ceipts during the fiscal year (as estimated by
the Secretary of the Treasury) from the taxes
imposed by sections 59 and 3111(b) of the In-
ternal Revenue Code of 1986;
(B) the amount of the aggregate obliga-
tions that the National Health Board deter-
mines were (or will be) incurred by the Service
from the Trust Fund during the previous fiscal
year, adjusted to reflect changes in the cost of
living, in the number of users, and in the capac-
ity of the Service to provide services under this
Act, as such changes are reflected in the plans
175
and budgets prepared and submitted by area
health boards under this subtitle; or
(C) the amount fixed under subsection (b).
(3) REFIXING.—The National Health Board
may at any time refix such amount to reflect
changes—
(A) of one percent or more in the expected
net tax receipts (described in paragraph
(2)(A)); or
(B) of five percent or more in the cost of
living, number of users, or the capacity of the
Service to provide services under this Act.
The National Health Board shall promptly report to
Congress any increase made in such amount and the
reasons therefor.
(b) LESSER AMOUNT.—The National Health Board
shall fix in a fiscal year an amount, which the maximum
amount described in subsection (a)(1) may not exceed in
the fiscal year, which is less than the amount described
in subsection (a)(2)(A) if the Board determines that—
(1) restriction of the amount to be made avail-
able for obligation will not materially impair the ade-
quacy or quality of health care and supplemental
services provided to users, or
176
(2) improvement in the organization, delivery,
or utilization of such services has lessened their ag-
gregate cost (or increase in such cost).
(c) OBLIGATION.—The National Health Board may
obligate for expenditure from the Trust Fund, in addition
to the maximum amount which may be obligated in a fis-
cal year under subsection (a), such funds as are necessary
to provide health care and supplemental services needed
because of an epidemic, disaster, or other occurrence
which was not, and could not have been, reasonably
planned for by the Board and for which the contingency
fund provided in section 534(b)(6) is insufficient. The Na-
tional Health Board shall promptly report to Congress any
obligation made pursuant to this subsection and the rea-
sons therefor.
(d) OBLIGATION OF BORROWED AMOUNTS.—In addi-
tion to the maximum amounts which may be obligated
pursuant to subsection (a), the National Health Board
may allocate funds borrowed in accordance with section
541 for such purposes as it deems necessary and appro-
priate.
SEC. 522. PREPARATION OF AREA PLANS AND BUDGETS.
(a) COMMUNITY BOARDS.—Each community board
shall, not later than January 1 of each year, submit to
its respective district board a plan and budget for the fis-
177
cal year beginning on October 1 of such year. In preparing
such plan and budget, each community board shall consult
with users and health workers in the community to assure
effective and coordinated planning for the efficient use of
resources in its community.
(b) DISTRICT BOARDS.—Each district board shall,
not later than February 1 of each year, submit to its re-
spective regional board a plan and budget for the fiscal
year beginning on October 1 of such year. In preparing
such plan and budget, each district board shall consult
with the users, health workers, and community boards in
its district to assure effective and coordinated planning for
the efficient use of resources in its district.
(c) REGIONAL BOARDS.—Each regional board shall,
not later than March 1 of each year, submit to the Na-
tional Health Board a plan and budget for the fiscal year
beginning on October 1 of such year. In preparing such
plan and budget, each regional board shall consult with
the users, health workers, and district boards in its region
to assure effective and coordinated planning for the effi-
cient use of resources in its region.
(d) BUDGET BREAKDOWNS.—In preparing the budg-
ets required by this section, each area health board shall
specify its operating, prevention, capital, and research ex-
penses anticipated for the fiscal year covered by the budg-
178
et and for the 5-year period beginning with such fiscal
year.
Subtitle D—Allocation and
Distribution of Funds
SEC. 531. NATIONAL BUDGET.
(a) PREPARATION.—The National Health Board
shall prepare, taking into consideration the budgets sub-
mitted under section 522(c), and, as soon after April 1
of each year as is practicable, shall transmit to the re-
gional boards a national health budget for the fiscal year
beginning on October 1 of such year. Such budget shall
divide the total funds available for obligation in such year,
as determined under section 521, into—
(1) funds for ordinary operating expenses,
which shall be further divided into funds for use by
the National Health Board, and funds to be allo-
cated (in accordance with subsection (b)) to the re-
gional boards for use by the regional boards and the
district and community boards within their regions;
(2) funds for preventive health measures, which
shall be further divided into funds for use by the
National Health Board and funds to be allocated (in
accordance with subsection (b)) to the regional
boards for use by the regional boards and the dis-
trict and community boards within their regions,
179
and which measures shall include primary prevention
to improve the conditions under which people live
that affect health status;
(3) funds for capital expenses, which shall be
further divided into funds for use by the National
Health Board and funds to be allocated (in accord-
ance with subsection (c)) to the regional boards for
use by the regional boards and district and commu-
nity boards within their regions;
(4) funds for research expenses, which shall be
further divided into funds for the conduct of re-
search under the supervision of the National Health
Board and funds to be allocated (in accordance with
subsection (b)) to the regional boards for the con-
duct of research under the supervision of the re-
gional, district, and community boards; and
(5) funds for special operating expenses, as de-
scribed in section 534.
(b) ORDINARY OPERATING EXPENSES.—Funds for
ordinary operating expenses, for preventive health meas-
ures, and for research expenses which are allocated to the
regional boards under subsection (a) shall be divided
among the regions in the proportion which the number
of residents in each region bears to the total population
of the Nation.