I
103D CONGRESS
2D SESSION
H. R. 4561
To amend the Public Health Service Act and the Social Security Act to
provide improved and expanded access to comprehensive primary health
care and related services for medically underserved and vulnerable popu-
lations through the establishment of financial support for the develop-
ment of community-based health networks and plans, to allow federally-
assisted health centers to expand their capacity and develop and operate
new sites to serve underserved and vulnerable populations, to provide
certain financial and other protections for such networks, plans, and
health centers, and to facilitate the involvement of, and payment to,
entities serving underserved and vulnerable populations in the training
and education of primary care health professionals.
IN THE HOUSE OF REPRESENTATIVES
JUNE 9, 1994
Mr. RANGEL (for himself, Mr. RICHARDSON, Mr. BONIOR, Mr. OWENS, Mr.
SANDERS, Mr. PARKER, Mrs. CLAYTON, Mr. RUSH, Mr. ABERCROMBIE,
Mrs. MEEK, Mr. OLVER, Mr. DELLUMS, Ms. VELA´ZQUEZ, Mr. BARRETT
of Wisconsin, and Mr. EDWARDS of California) introduced the following
bill; which was referred jointly to the Committees on Energy and Com-
merce and Ways and Means
A BILL
To amend the Public Health Service Act and the Social
Security Act to provide improved and expanded access
to comprehensive primary health care and related serv-
ices for medically underserved and vulnerable populations
through the establishment of financial support for the
development of community-based health networks and
plans, to allow federally-assisted health centers to expand
their capacity and develop and operate new sites to serve
underserved and vulnerable populations, to provide cer-
tain financial and other protections for such networks,
plans, and health centers, and to facilitate the involve-
ment of, and payment to, entities serving underserved
and vulnerable populations in the training and education
of primary care health professionals.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Access to Community Health Care Act of 1994’’.
(b) FINDINGS.—The Congress finds the following:
(1) Efforts to assure universal coverage for
comprehensive benefits are a vitally important part
of achieving effective national health care reform.
(2) The provision of universal insurance cov-
erage, while vitally important, will not alone address
the critical needs of the estimated 3 million Ameri-
cans who are underserved by the current health care
system, and who lack access to the most basic health
services.
(3) Access to, and coordination of, health care
is especially difficult for those Americans who live in
underserved rural and inner-city communities or who
are members of other vulnerable groups, including
migratory and seasonal agricultural workers, persons
who are homeless, those with HIV infection, those
who suffer from substance addiction, high-risk preg-
nant women, infants and children, immigrants and
refugees, and persons with disabilities.
(4) The consequences of poor access to, and
lack of coordination of, health care among the un-
derserved is evidenced by elevated infant and child-
hood illness and mortality rates, over-utilization of
emergency rooms and other inappropriate providers
for primary care services, and hospitalization rates
for preventable conditions that are significantly
higher than the national average.
(5) Efforts to provide increased access to, and
coordinate the delivery of, vital primary health care
and related services for underserved and vulnerable
Americans will not only contribute to improved
health status, but will also reduce unnecessary care
and the overall costs of health care.
(6) Essential community providers, such as the
community and migrant health centers, collectively
referred to as health centers, which serve more than
7 million needy Americans, provide an effective and
proven model for extending access to all underserved
and vulnerable Americans.
(7) Support for the development and operation
of new and expanded sites served by the health cen-
ters and similar primary health care providers, is
needed to extend access to comprehensive primary
health care services for the millions of Americans
who remain unserved or underserved.
(8) As managed care has achieved recognition
as a means of organizing and paying for health care
for many Americans, there is a need to assure that
such arrangements develop in a manner that is re-
sponsive to the needs of underserved people and
communities. Of particular importance is develop-
ment of community-based networks of health centers
and other essential community providers that offer
high quality care to individuals and that endeavor to
both contain costs and reduce unnecessary or inap-
propriate use of high-cost services.
(9) Essential community providers such as
health centers and community-based networks serv-
ing such populations must be afforded certain pro-
tections from full financial risk for the cost of serv-
ing such populations and communities. Protections
are needed because underserved populations typically
require more frequent and intensive care, and be-
cause reduced use of higher-cost inpatient, emer-
gency and specialty care will depend on increased
provision of primary care as well as related and ena-
bling services.
(10) Health centers and community-based net-
works that participate in arrangements which
produce savings of grant funds or increased revenues
that will be used to further expand or improve serv-
ices to medically underserved populations should be
afforded protection from anti-kickback laws.
(11) Health centers, community-based networks
and other essential community providers of com-
prehensive primary care services to the underserved
provide the most appropriate locations and condi-
tions for educating and training primary health care
professionals, and should be centrally involved in
such education and training efforts.
SEC. 2. GRANTS FOR THE DEVELOPMENT AND OPERATION
OF 
HEALTH 
CENTERS 
AND 
COMMUNITY
HEALTH NETWORKS AND HEALTH PLANS.
(a) ENABLING AND OUTREACH SERVICES.—Section
330(a) of the Public Health Service Act (42 U.S.C.
254c(a)) is amended—
(1) in paragraph (5), by striking ‘‘and’’ at the
end;
(2) in paragraph (6), by inserting before ‘‘pa-
tient case management services’’ the following: ‘‘the
services of outreach workers and others to deter-
mine, or assist in determining, the eligibility of indi-
viduals to receive services and benefits under Fed-
eral, State and local health programs, and to assist
such individuals in enrolling in such programs, and
other’’;
(3) in paragraph (6), by adding ‘‘and’’ after the
comma at the end; and
(4) by inserting after paragraph (6) the follow-
ing new paragraph:
‘‘(7) enabling services, defined as services that
are not otherwise described in this subsection, that
promote access to necessary health and other human
and social services, and that increase the capacity of
individuals to utilize the items and services included
as covered benefits under Federal, State, and local
health programs,’’.
(b) SERVICES AUTHORIZED AT SCHOOLS AND OTHER
APPROPRIATE LOCATIONS.—Section 330(a) of the Public
Health Service Act (42 U.S.C. 254c(a)) is amended in
the matter preceding paragraph (1) by striking ‘‘pro-
vides—’’ and inserting the following: ‘‘provides, at appro-
priate locations, which may include schools and other
sites—’’.
(c) COMMUNITY HEALTH SERVICE NETWORKS AND
PLANS.—Section 330 of the Public Health Service Act (42
U.S.C. 254c) is amended by adding at the end the follow-
ing subsection:
‘‘(l)(1) The Secretary may make a grant to one or
more community health centers that receive grants under
subsection (d)(l)(A), or to one or more Federally qualified
health centers as defined in section 1861(aa)(4) of the So-
cial Security Act, to support the development of a commu-
nity health service network or plan as defined in para-
graph (3). The costs for which a grant may be made under
this paragraph include, but are not limited to—
‘‘(A) costs of developing the network or plan as
a corporate entity, including planning and needs as-
sessment, and costs of developing appropriate con-
tractual agreements between the participating pro-
viders and the network or plan;
‘‘(B) costs of development of internal manage-
ment for the network or plan, as well as costs of de-
velopment of financial, legal, clinical, information
systems (exclusive of systems that the Secretary de-
termines are information highways), billing and re-
porting systems for the network or plan;
‘‘(C) costs of development of additional sites
that will assure or enhance the provision and acces-
sibility of primary health care and enabling services
to medically underserved populations, and residents
of health professional shortage areas;
‘‘(D) costs of recruitment, training, compensa-
tion of health professionals and administrative staff;
‘‘(E) costs of acquisition, expansion, moderniza-
tion of facilities, conversion of unneeded hospital fa-
cilities to facilities that will assure or enhance the
provision and accessibility of primary health care
and enabling services, as well as construction of new
facilities and purchase of major equipment (includ-
ing equipment necessary for support of external and
internal information systems);
‘‘(F) reserves required for furnishing services
on a prepaid basis; and
‘‘(G) such other costs as are necessary to as-
sure that the network or plan will be ready to as-
sume operational status by the end of the planning
and development phase.
‘‘(2) The Secretary may make grants to support the
operation of community health service networks or plans
which received support under paragraph (1) for planning
and development and which meet the requirements of sub-
paragraphs (A) and (B) of paragraph (3). The costs for
which a grant may be made include, but are not limited
to, the costs described in paragraph (1), and the otherwise
unreimbursed costs of furnishing services described in sub-
section (a) (except for the costs of inpatient hospital serv-
ices, extended care facility services and long-term physical
medicine) to medically underserved populations and resi-
dents of health professional shortage areas and other
hard-to-reach populations.
‘‘(3)(A)(i) For purposes of this section, the term
‘community health service network’ means a consortium
of health care providers that meets the following require-
ments:
‘‘(I) The consortium is a public or nonprofit
private entity whose principal purpose is, with re-
spect to the items and services that are described in
subsection (a), to provide all or a portion of such
items and services to a significant number of indi-
viduals who are members of a medically underserved
population or populations, residents of health profes-
sional shortage areas and other hard-to-reach popu-
lations in the network service area.
‘‘(II) The participation of health care providers
in the consortium is governed by a written agree-
ment to which each of the participating providers is
a party.
‘‘(ii) For purposes of this section, the term ‘commu-
nity health service plan’ means a health plan that meets
the following conditions:
‘‘(I) The health plan is a public or nonprofit
private entity, as defined in section 1903(m)(2)(A)
of the Social Security Act, whose principal purpose
is, with respect to the items and services that are
described in subsection (a) to provide all or a por-
tion of the items and services to a significant num-
ber of individuals who are members of a medically
underserved population or populations, residents of
health professional shortage areas in the plan’s serv-
ice area, and other hard-to-reach populations in the
plan’s service area.
‘‘(II) The participation of health care providers
in the health plan is governed by a written agree-
ment to which each of the participating providers is
a party.
‘‘(B) A community health service network or plan
must—
‘‘(i) be governed by individuals a majority of
whom are registered patients of the network or plan
or are representatives of the entities described in
clause (iv)(I), or a combination of such individuals;
‘‘(ii) assure the provision of services through
participating providers (who may provide services di-
rectly or through contract) in accordance with all re-
quirements of subsection (e)(3) except subparagraph
(G);
‘‘(iii) be reasonable in size to accomplish the ob-
jectives of this section;
‘‘(iv) include as participating providers (unless
such provider(s) decline to participate): (I) at a min-
imum, all entities providing health services under
grants under this section or section 329 or 340, and
other Federally qualified health centers certified in
accordance with section 1861(aa)(4) of the Social
Security Act in the service area of the plan or net-
work; (II) a reasonable number and combination (to
assure that services will be comprehensive and acces-
sible) of public or nonprofit private entities that are
entities providing health services under grants under
section 340A, 1001, or title XXIII, under title V of
the Social Security Act, under title V of the Indian
Health Care Improvement Act, and under the Indian
Self-Determination Act; that are rural health clinics
certified in accordance with section 1861(aa)(2) of
levels of support previously received from other
sources have been maintained.
‘‘(5) No more than two grants may be made for plan-
ning and developing the same network or plan.’’.
(d) FLEXIBLE AUTHORITY.—Section 330 of the Pub-
lic Health Service Act, as amended by subsection (c) of
this subsection, is amended by adding at the end the fol-
lowing subsection:
‘‘(m)(1) The Secretary may make grants to public
and nonprofit private entities that meet all of the require-
ments of subsection (l), except for paragraph (3)(B)(i)
and such other requirements of that subsection as the Sec-
retary may decide for good cause to waive, for the purpose
of planning, development and operation of health networks
and health plans as the Secretary determines will provide
or enhance the provision and accessibility of the services
that are described in subsection (a) to medically under-
served populations and health professional shortage areas
in the service area of the network or plan.
‘‘(2) An application for a planning and development
grant must meet the requirements of clause (i) of sub-
section (l)(4)(A) and an application for an operations
grant must meet the requirements of clause (ii) of such
subsection.
‘‘(3)(A) In evaluating applications submitted under
paragraph (2), the Secretary will consider the factors de-
scribed in subsection (l)(4)(B).
‘‘(B) The Secretary may not approve an application
for a grant under this subsection unless the Secretary de-
termines that the network or plan will at a minimum as-
sure significant community involvement. For purposes of
this subsection, ‘significant community involvement’ is
demonstrated if the health network, or health plan (i) is
governed by a board of directors, at least one-third of the
members of which are registered patients or representa-
tives of entities described in subsection (l)(3)(B)(iv)(I), or
a combination of such individuals; or (ii) has established
a patient advisory council, composed of representative reg-
istered patients of the network or plan, through which reg-
istered patients are able to directly participate in decisions
that influence the character and implementation of pro-
grams of the network or plan. The Secretary shall give
priority to applicants that meet the requirements of clause
(i) over applicants that meet the requirements of clause
(ii).
‘‘(4) No more than two grants may be made for plan-
ning and developing the same health network or health
plan.
‘‘(5) The costs for which a grant may be made under
this subsection for planning and development of a health
network or health plan may include the costs described
in paragraph (1) of subsection (l), and the costs for which
a grant may be made for operation of such a health net-
work or health plan may include the costs described in
paragraph (2) of such subsection.’’.
(e) AUTHORIZATION OF APPROPRIATIONS.—(1) Sec-
tion 330(g)(1)(A) of the Public Health Service Act (42
U.S.C. 254c(g)(1)(A)) is amended by striking ‘‘there are
authorized’’ and all that follows and inserting the follow-
ing: 
‘‘there 
are 
authorized 
to 
be 
appropriated
$925,000,000 for fiscal year 1995, $1,425,000,000 for fis-
cal year 1996, $1,625,000,000 for fiscal year 1997,
$1,725,000,000 for fiscal year 1998, $1,725,000,000 for
fiscal year 1999, $1,725,000,000 for fiscal year 2000, and
such sums equal to or greater than $1,725,000,000 as
may be necessary for each of the fiscal years 2001 through
2005. The preceding sentence constitutes budget authority
in advance of appropriations acts and represents the obli-
gation of the Federal government to provide funding for
payments in the amounts, and for the fiscal years specified
under this section. Such levels shall not be subject to offset
or reprogramming for any reason.’’.
(2) Section 330(g)(1) of the Public Health Service
Act (42 U.S.C. 254c(g)(1)) is amended by adding at the
end the following new subparagraph:
‘‘(C)(i) For the purpose of making grants for activi-
ties authorized under subsection (m), the Secretary is au-
thorized to expend up to 15 percent of the amounts appro-
priated under subparagraph (A) for a fiscal year that are
in excess of $625,000,000. The authority of the Secretary
to make grants for such activities is effective for any fiscal
year only to such extent or in such amounts exceeding
$625,000,000 as are provided in appropriation Acts; and
(ii) for the purpose of making grants under subsections
(c) and (d), the Secretary shall spend not less than
$625,000,000 each year.’’.
(f) FUNDING PREFERENCES.—Section 330(k) of the
Public Health Service Act (42 U.S.C. 254c(k)) is amend-
ed—
(1) by inserting ‘‘(1)’’ after ‘‘(k)’’; and
(2) by adding at the end the following new
paragraph:
‘‘(2) In making grants under this section, the Sec-
retary shall give preference as follows:
‘‘(A) As between an application for a grant
under subsection (l) to plan, develop or operate a
community health service network or plan and an
application for a grant under subsection (m) to plan,
develop or operate a health network or plan serving
the same medically underserved population, the Sec-
retary shall give preference to the applicant that is
or will be a community health service plan or net-
work in accordance with subsection (l).
‘‘(B) As between two or more applications
under subsection (m) to serve the same medically
underserved population, preference shall be given to
applicants that include as participating providers the
greatest number of entities providing health services
under grants under section 329, this section, and
section 340.’’
(g) MISCELLANEOUS
AND CONFORMING AMEND-
MENTS.—
(1) Section 330(c)(1)(A) of the Public Health
Service Act (42 U.S.C. 254c(c)(1)(A)) is amended
by inserting ‘‘enabling services,’’ before ‘‘primary
health services,’’.
(2) Section 330(c) of the Public Health Service
Act (42 U.S.C. 254c(c)) is amended—
(A) in paragraph (1), in the matter preced-
ing subparagraph (A), by striking ‘‘loans) and
shall include—’’ and inserting ‘‘loans).’’; and
(B)(i) by transferring subparagraphs (A)
through (D) of paragraph (1) from the current
placement of the subparagraphs;
(ii) by inserting before such subparagraph
(A) the following:
‘‘(4) No grant may be made under paragraph (1) un-
less an application therefor is submitted to and approved
by, the Secretary. Such an application shall be submitted
in such form and manner and contain such information
as the Secretary may prescribe, and shall include:’’; and
(iii) by adding paragraph (4) (as so des-
ignated) at the end.
(3) Section 330(e)(2) of the Public Health
Service Act (42 U.S.C. 254c(e)(2)) is amended—
(A) by striking ‘‘a grant under’’ in the
matter preceding subparagraph (A) and all that
follows through ‘‘also include a demonstration’’
and inserting the following: ‘‘a grant under sub-
section (d)(1) shall include a demonstration’’;
and
(B) by adding at the end the following sen-
tence: ‘‘An application for a grant under sub-
paragraph (B) of subsection (d)(1) must dem-
onstrate how the entity will meet all of the re-