II 113th CONGRESS 2d Session S. 2229 IN THE SENATE OF THE UNITED STATES April 9, 2014 Mr. Sanders introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To expand primary care access.

1. Short title This Act may be cited as the Expanding Primary Care Access and Workforce Act . 2. Scholarships and Loan Repayment Opportunities for Primary Care Providers (a) Funding for the National Health Service Corps Section 338 of the Public Health Service Act ( 42 U.S.C. 254k ) is amended by adding at the end the following: (c) Scholarship and loan repayment opportunities for primary care providers (1) In general There is authorized to be appropriated, and there is appropriated, out of any amounts in the Treasury not otherwise appropriated, $4,900,000,000 for the period of fiscal years 2015 through 2020, to provide for a continuation and expansion of the program with respect to required primary health services, as defined in section 330(b), under this subpart. (2) Supplemental funding Amounts appropriated under this subsection shall be used to supplement and not supplant other amounts appropriated to carry out programs under this subpart. . (b) Scholarship program and student loan repayment program Section 338H of the Public Health Service Act ( 42 U.S.C. 254q ) is amended by adding at the end the following: (d) Distribution of funds In allocating funds made available to the Health Resources and Services Administration for the National Health Service Corps, the Secretary shall provide loan repayment awards to at least 6 individuals in each State and scholarships to at least 3 individuals in each State. . (c) Public information programs in designated areas Section 332(h) of the Public Health Service Act ( 42 U.S.C. 254e(h) ) is amended by inserting (directly, or by grant, contract, or cooperative agreement) after conduct . (d) Professional development Section 336(d)(1) of the Public Health Service Act ( 42 U.S.C. 254h–1(d)(1) ) is amended by inserting (directly, or by grant, contract, or cooperative agreement) after shall assist . 3. Funding for health centers Section 10503(b)(1) of the Patient Protection and Affordable Care Act of 2010 ( 42 U.S.C. 254b–2 ) is amended— (1) in subparagraph (D), by striking and at the end; (2) in subparagraph (E), by striking and at the end; and (3) by inserting after subparagraph (E) the following: (F) $3,800,000,000 for fiscal year 2016; (G) $4,300,000,000 for fiscal year 2017; (H) $4,900,000,000 for fiscal year 2018; (I) $5,600,000,000 for fiscal year 2019; and (J) $6,400,000,000 for fiscal year 2020; and . 4. Increasing the Primary Care Provider Workforce (a) Reauthorization of the teaching health centers program Section 340H of the Public Health Service Act ( 42 U.S.C. 256h ) is amended— (1) in subsection (a), by striking subsection (h)(2) and inserting subsection (i)(2) ; (2) in subsection (g)— (A) by striking such sums and all that follows through the period at the end and inserting $800,000,000 for the period of fiscal years 2016 through 2020. ; and (B) by adding at the end the following: Any amounts appropriated under this subsection for any of fiscal years 2011 through 2020 and remaining unexpended at the end of the fiscal year involved may be used in subsequent fiscal years to carry out this section. ; (3) in subsection (h)(2)— (A) in the paragraph heading, by adding at the end the following: ; submission to Congress ; and (B) by adding at the end the following: (C) Submission to Congress The Secretary shall annually submit to Congress a report that contains a compilation of the data submitted to the Secretary under paragraph (1) for the year involved. ; (4) by redesignating subsections (h) through (j) as subsections (i) through (k), respectively; and (5) by inserting after subsection (g), the following: (h) Limitation The Secretary shall establish a minimum per resident per year payment amount for funding of all approved teaching health center graduate medical education positions under this section that shall be not less than the per resident per year payment amount as of January 1, 2013, and ensure that not less than such amount is provided to all teaching health center graduate medical education programs for all approved positions. . (b) Teaching health centers development grants Section 749A(g) of the Public Health Service Act ( 42 U.S.C. 293l–1(g) ) is amended by striking each fiscal year thereafter and inserting each of fiscal years 2013 through 2020 and each fiscal year thereafter . (c) National Health Care Workforce Commission Section 5101 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 294q ) is amended— (1) in subsection (h)— (A) by striking paragraphs (1) and (2) and inserting the following: (1) Appropriations There are authorized to be appropriated, and there are appropriated, out of any monies in the Treasury not otherwise appropriated, $10,000,000 for each fiscal year to carry out this section. ; and (B) by redesignating paragraph (3) as paragraph (2); and (2) in subsection (d)— (A) in paragraph (7), by adding at the end Whenever feasible, Congress and the Department of Health and Human Services shall recognize and implement such recommendations. ; and (B) by adding at the end the following: (9) Data tracking (A) Data tracking mechanism The Commission shall develop, or enter into a contract with another entity to develop, a mechanism for tracking information on the career paths of graduates of medical schools and residency programs, as described in subparagraph (B), and shall make such information publicly available. (B) Recordkeeping The Commission shall collect or ensure the collection of data, using the mechanism developed under subparagraph (A), concerning— (i) the specialty and subspecialty training of all graduates of medical schools receiving Federal funding; and (ii) the professional trajectory of all graduates of medical schools receiving Federal funding for not less than 15 years after each individual graduates from medical school, including data concerning graduates who practice medicine— (I) in underserved areas such as health professional shortage areas (as defined by the National Health Service Corps under section 332 of the Public Health Service Act (42 U.S.C. 254e)); (II) with medically underserved populations (as defined in section 330(b)(3) of the Public Health Service Act ( 42 U.S.C. 254b(b)(3) )); (III) in Federally qualified health centers (as defined in section 1905(l)(2)(B) of the Social Security Act ( 42 U.S.C. 1396d(l)(2)(B) )); (IV) rural health clinics (under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. )); (V) the health care system of the Department of Veterans Affairs; and (VI) clinics of the Indian Health Services. . (d) Reauthorization of family nurse practitioner residency training program Section 5316(i) of the Patient Protection and Affordable Care Act (42 U.S.C. 296j–1(i)) is amended by striking such sums and all that follows through the period at the end and inserting $75,000,000 for the period of fiscal years 2015 through 2019. . (e) Reauthorization of nurse faculty loan program Section 846A(f) of the Public Health Service Act ( 42 U.S.C. 297n–1(f) ) is amended by striking 2014 and inserting 2019 . (f) Reauthorization of primary care residency expansion program Section 747(c)(1) of the Public Health Service Act ( 42 U.S.C. 293k(c)(1) ) is amended by striking $125,000,000 and all that follows through the period at the end and inserting $168,000,000 for the period of fiscal years 2015 through 2019. . (g) Reauthorization of the area health education centers Section 751(j)(1) of the Public Health Service Act ( 42 U.S.C. 294a(j)(1) ) is amended by striking 2010 through 2014 and inserting 2015 through 2019 . 5. Increasing payment for primary care (a) Requirement concerning consultation with organizations or other entities In determining physician fees for the purpose of payments under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ), the Secretary of Health and Human Services shall not consult with an organization or other entity representing physicians unless at least 50 percent of the members of such organization or entity, at the time of such consultation, are primary care physicians. (b) Incentive payment program for primary care services Section 1833(x)(1) of the Social Security Act ( 42 U.S.C. 1395l(x)(1) ) is amended by striking 2016 and inserting 2020 . (c) Permanent application of Medicare payment rate floor to primary care services furnished under Medicaid (1) In general Section 1902(a)(13)(C) of the Social Security Act ( 42 U.S.C. 1396a(a)(13)(C) ) is amended by striking and 2014 and inserting or any year thereafter . (2) Increased FMAP Section 1905(dd) of the Social Security Act ( 42 U.S.C. 1396d(dd) ) is amended by striking and before January 1, 2015, . (3) Effective date The amendments made by this subsection take effect on January 1, 2015. 6. Accountability for Federal funds at medical schools (a) Family medicine or primary care department A medical school that receives Federal funds for any purpose shall— (1) maintain in such medical school a family medicine or primary care department; and (2) require for all students at least 8 weeks of rotations in family medicine or community-oriented primary care during the third year of training. (b) Reporting on meeting health care workforce needs A medical school that receives Federal funds for any purpose shall— (1) prepare an annual report— (A) responding to the data with respect to such medical school that is collected under section 5101(d)(9) of the Patient Protection and Affordable Care Act (as added by section 4(c)(2)(B)); and (B) detailing the actions the medical school is taking to meet the health care workforce needs in the school's community and across the Nation; and (2) submit such report to the Secretary of Health and Human Services and the National Health Care Workforce Commission. 7. Increasing opportunities and accountability for primary care residency training (a) Additional residency positions for training in family medicine (1) In general Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended— (A) in paragraph (4)(F)(i), by striking paragraphs (7) and (8) and inserting paragraphs (7), (8), and (9) ; (B) in paragraph (4)(H)(i), by striking paragraphs (7) and (8) and inserting paragraphs (7), (8), and (9) ; (C) in paragraph (7)(E), by inserting paragraph (9), after paragraph (8), ; and (D) by adding at the end the following new paragraph: (9) Additional residency positions for training in family medicine (A) In general (i) Distribution For fiscal year 2014 (and succeeding fiscal years if the Secretary determines that there are additional residency positions available to distribute under subparagraph (D)), the Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits a timely application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1 of the fiscal year of the increase. Such additional residency positions shall be for approved medical residency training programs (as defined in paragraph (5)(A)) in family medicine. (ii) Requirements Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this paragraph shall ensure, during the 5-year period beginning on the date of such increase, that— (I) the number of full-time equivalent residents in family medicine (as determined by the Secretary), excluding any additional positions under subclause (II), is not less than the average number of full-time equivalent residents in family medicine (as so determined) during the 3 most recent cost reporting periods ending prior to the date of enactment of this paragraph; and (II) 100 percent of the positions attributable to such increase are in an approved medical residency training program in family medicine (as determined by the Secretary). (iii) Redistribution of positions if hospital no longer meets certain requirements In the case where the Secretary determines that a hospital described in clause (ii) does not meet either of the requirements under subclause (I) or (II) of such clause, the Secretary shall— (I) reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this paragraph; and (II) provide for the distribution of positions attributable to such reduction in accordance with the requirements of this paragraph. (B) Aggregate number of increases The aggregate number of increases in the otherwise applicable resident limit under this paragraph shall be equal to 2,000. (C) Timing The Secretary shall notify hospitals of the number of positions distributed to the hospital under this paragraph as result of an increase in the otherwise applicable resident limit by January 1 of the fiscal year of the increase. Such increase shall be effective for portions of cost reporting periods beginning on or after July 1 of that fiscal year. (D) Positions not distributed during fiscal year 2014 If the number of resident full-time equivalent positions distributed under this paragraph in fiscal year 2014 is less than the aggregate number of positions available for distribution in the fiscal year under subparagraph (B), the Secretary shall conduct an application and distribution process in subsequent fiscal years until such time as the aggregate number of positions distributed under this paragraph is equal to the aggregate number under subparagraph (B). (E) Consideration in distribution In determining for which hospitals the increase in the otherwise applicable resident limit is provided under this paragraph, the Secretary shall prioritize training programs with an emphasis on community-based training, and shall prioritize hospitals with a demonstrated likelihood of filling the positions with residents who will practice in health professional shortage areas (as defined by the National Health Service Corps under section 332 of the Public Health Service Act (42 U.S.C. 254e)) or with medically underserved populations (as defined in section 330(b)(3) of the Public Health Service Act ( 42 U.S.C. 254b(b)(3) )), as determined by the Secretary. (F) Definition of otherwise applicable resident limit In this paragraph, the term otherwise applicable resident limit means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level (as defined in paragraph (7)(C)(i)) for the hospital determined without regard to this paragraph but taking into account paragraphs (7)(A), (7)(B), (8)(A), and (8)(B). . (2) IME (A) In general Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, is amended by striking subsections (h)(7) and (h)(8) and inserting subsections (h)(7), (h)(8), and (h)(9) . (B) Conforming provision Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— (i) by redesignating clause (x), as added by section 5505(b) of the Patient Protection and Affordable Care Act ( Public Law 111–148 ), as clause (xi) and moving such clause 4 ems to the left; and (ii) by adding after clause (xi), as redesignated by subparagraph (A), the following clause: (xii) For discharges occurring on or after July 1, 2014, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(9), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions. . (b) Requirements To improve transparency (1) In general Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), as amended by subsection (a)(1), is amended by adding at the end the following new paragraph: (10) Requirements (A) In general Notwithstanding the preceding provisions of this subsection, for fiscal year 2014 and subsequent fiscal years, a hospital shall not receive any payments under this subsection or subsection (d)(5)(B) (or any other payments under this title for graduate medical education costs) in a fiscal year unless the hospital complies with the following requirements, as determined by the Secretary: (i) The hospital has an approved medical residency program in— (I) family medicine; or (II) adult or all-age primary care. (ii) Each fiscal year (beginning with fiscal year 2014), the hospital submits to the Secretary a report that contains the following information with respect to residents of the hospital: (I) The total amount of money generated by the residents (by residency type) in each year of their residency program. (II) The total amount of Federal funding provided to the hospital for training residents, by residency type, in each year of the residency program. (III) The average number of inpatient and outpatient encounters per year by residency type in inpatient and outpatient settings. (IV) A justification for the hospital’s allocation of residency slots across specialties and subspecialties that is responsive to local and national health care workforce needs and recommendations put forth by the National Health Care Workforce Commission. (V) A detailed breakdown of how the hospital uses amounts received under this subsection and under subsection (d)(5)(B). (B) Public availability Not later than 30 days after receiving the report under subparagraph (A)(ii), the Secretary shall post the information described in subclauses (I) through (VI) of such subparagraph on the Internet Website of the Centers for Medicare & Medicaid Services. . (2) IME Section 1886(d)(5)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(5)(B) ), as amended by subsection (a)(2)(B), is amended by adding at the end the following new clause: (xiii) The requirements under subsection (h)(10) shall apply to payments under this subparagraph in the same manner as such requirements apply to payments under such subsection. . 8. Health care for the uninsured A hospital or health care provider that accepts any payment under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) or the Medicaid program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) shall not charge an individual without health insurance coverage an amount for any medical service that exceeds the amount such hospital or health care provider receives under the Medicare program for such service.