II 114th CONGRESS 2d Session S. 3190 IN THE SENATE OF THE UNITED STATES July 13, 2016 Mr. Franken (for himself and Ms. Heitkamp ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To enhance the rural health workforce, and for other purposes.

1. Short title This Act may be cited as the Strengthening Our Rural Health Workforce Act of 2016 . 2. Table of contents The table of contents for this Act is as follows: Sec. 1. Short title. Sec. 2. Table of contents. TITLE I—Comprehensive strategic planning for workforce needs Sec. 101. National Health Care Workforce Commission. TITLE II—Increasing the adoption of rural training track programs Sec. 201. Clarifying description of rural training tracks. Sec. 202. GAO study and report on Medicare payments for graduate medical education. Sec. 203. Distribution of additional residency positions. TITLE III—Supporting primary care workforce Sec. 301. Reauthorization of primary care residency expansion program. Sec. 302. Reauthorization of area health education centers. TITLE IV—Supporting emerging professions Sec. 401. Authorizing appropriations for Quentin N. Burdick program for rural interdisciplinary training. Sec. 402. Dental therapists. Sec. 403. Allied health professionals. Sec. 404. Community health workers. Sec. 405. GAO report. TITLE V—Mental health workforce Sec. 501. Establishing mental health and substance use disorder curriculum. Sec. 502. Streamlining mental and behavioral health workforce programs. I Comprehensive strategic planning for workforce needs 101. National Health Care Workforce Commission Section 5101 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 294q ) is amended— (a) in subsection (h)— (1) 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 (2) by redesignating paragraph (3) as paragraph (2); and (b) in subsection (d)— (1) 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 (2) 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 designated by the Secretary 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) in rural health clinics (as defined in section 1861(aa)(2) of the Social Security Act ( 42 U.S.C. 1395x(aa)(2) )); (V) in the health care system of the Department of Veterans Affairs; and (VI) in clinics of the Indian Health Services. . II Increasing the adoption of rural training track programs 201. Clarifying description of rural training tracks Section 1886(h)(4)(H)(iv) of the Social Security Act ( 42 U.S.C. 1395ww(h)(4)(H)(iv) ) is amended by adding at the end the following new sentence: The Secretary, in coordination with representatives of the Centers for Medicare & Medicaid Services, the Health Resources Services Administration, and the Federal Office of Rural Health Policy, shall develop a consistent definition of approved medical residency training programs (or rural tracks) in a rural area for purposes of this section and any other residency training program administered by the Secretary. . 202. GAO study and report on Medicare payments for graduate medical education (a) Study The Comptroller General of the United States shall conduct a study on the effectiveness of payments for graduate medical education costs and indirect costs for medical education under subsections (h) and (d)(5)(B) of section 1886 of the Social Security Act ( 42 U.S.C. 1395ww ), including efforts to distribute unused residency positions under subsection (h)(8) of such section, to meet the primary care and mental health needs of individuals living in rural areas. Such study shall include— (1) an analysis of the number of additional residency positions available as a result of such distribution that are being used to train residents who practice in rural areas after completing their residency; and (2) identification of approved medical residency training programs with proven track records in training primary care physicians and psychiatrists who practice in rural areas. (b) Report Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate. 203. Distribution of additional residency positions (a) In general Section 1886(h) of the Social Security Act ( 42 U.S.C. 1395ww(h) ) is amended— (1) in paragraph (4)(F)(i), by striking and (8) and inserting , (8), and (9) ; (2) in paragraph (4)(H)(i), by striking and (8) and inserting , (8), and (9) ; (3) in paragraph (7)(E), by inserting paragraph (9), after paragraph (8), ; and (4) by adding at the end the following new paragraph: (9) Distribution of additional residency positions (A) Reductions in limit based on unused positions (i) In general Except as provided in clause (ii), if a hospital's reference resident level (as defined in subparagraph (H)) is less than the otherwise applicable resident limit (as defined in such subparagraph), effective for portions of cost reporting periods occurring on or after July 1, 2020, the otherwise applicable resident limit shall be reduced by 65 percent of the difference between such otherwise applicable resident limit and such reference resident level. (ii) Exceptions This subparagraph shall not apply to— (I) a hospital with fewer than 250 acute care inpatient beds that is located in a rural area (as defined in subsection (d)(2)(D)(ii)), including a hospital treated as being located in a rural area under subsection (d)(8)(E); (II) a hospital that was part of a qualifying entity which had a voluntary residency reduction plan approved under paragraph (6)(B) or under the authority of section 402 of Public Law 90–248 , if the hospital demonstrates to the Secretary that it has a specified plan in place for filling the unused positions by not later than 2 years after the date of enactment of this paragraph; or (III) a hospital described in paragraph (4)(H)(v). (B) Distribution (i) In general The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2020. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the aggregate reduction in such limits attributable to subparagraph (A) (as estimated by the Secretary). (ii) Requirements Subject to clause (iii), a hospital that receives an increase in the otherwise applicable resident limit under this subparagraph shall ensure, during the 5-year period beginning on the date of such increase, that— (I) the number of full-time equivalent primary care residents, as defined in paragraph (5)(H) (as determined by the Secretary), excluding any additional positions under subclause (II), is not less than the average number of full-time equivalent primary care residents (as so determined) during the 3 most recent cost reporting periods ending prior to the date of enactment of this paragraph; and (II) not less than 75 percent of the positions attributable to such increase are in a primary care, psychiatry, or general surgery residency (as determined by the Secretary). The Secretary may determine whether a hospital has met the requirements under this clause during such 5-year period in such manner and at such time as the Secretary determines appropriate, including at the end of such 5-year period. (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. (C) Considerations in redistribution In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), the Secretary shall take into account— (i) the demonstration likelihood of the hospital filling the positions made available under this paragraph within the first 3 cost reporting periods beginning on or after July 1, 2020, as determined by the Secretary; and (ii) whether the hospital has an accredited rural training track (as described in paragraph (4)(H)(iv)). (D) Priority for certain areas In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B), subject to subparagraph (E), the Secretary shall distribute the increase to hospitals based on the following factors: (i) Whether the hospital and the approved medical residency training program of the hospital have a proven track record of primary care and rural support (as determined by the Secretary). (ii) Whether the hospital is located in a State, a territory of the United States, or the District of Columbia that is among the top 20 States, territories, or Districts in terms of the ratio of the geographic area of the State, territory, or District in square miles that is rural compared to the geographic area in each other State, territory, or District in square miles that is rural (as determined by the Secretary based solely on the most recent available population data published by the Bureau of the Census). (iii) Whether the hospital is located in a rural area (as defined in subsection (d)(2)(D)(ii)), including a hospital treated as being located in a rural area under subsection (d)(8)(E). (E) Reservation of positions for certain hospitals (i) In general Subject to clause (ii), the Secretary shall reserve the positions available for distribution under this paragraph as follows: (I) 70 percent of such positions for distribution to hospitals described in clause (i) of subparagraph (D). (II) 30 percent of such positions for distribution to hospitals described in clauses (ii) and (iii) of such subparagraph. (ii) Exception if positions not redistributed by July 1, 2020 In the case where the Secretary does not distribute positions to hospitals in accordance with clause (i) by July 1, 2020, the Secretary shall distribute such positions to other hospitals in accordance with the considerations described in subparagraph (C) and the priority described in subparagraph (D). (F) Limitation A hospital may not receive more than 75 full-time equivalent additional residency positions under this paragraph. (G) Application of per resident amounts for primary care and nonprimary care With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital. (H) Definitions In this paragraph, the terms reference resident level , resident level , and otherwise applicable resident limit have the meaning given such terms in paragraph (8)(H). (I) Affiliation The provisions of this paragraph shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) and the reference resident level for each such hospital shall be the reference resident level with respect to the cost reporting period that results in the smallest difference between the reference resident level and the otherwise applicable resident limit. . (b) IME (1) 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 and (h)(8) and inserting , (h)(8), and (h)(9) . (2) Conforming amendment Section 1886(d)(5)(B) of the Social Security Act ( 42 U.S.C. 1395ww(d)(5)(B) ) is amended by adding at the end the following new clause: (xi) For discharges occurring on or after July 1, 2020, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(9)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions. . (c) Conforming amendment Section 422(b)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ( Public Law 108–173 ) is amended by striking and (8) and inserting , (8), and (9) . III Supporting primary care workforce 301. Reauthorization of primary care residency expansion program Section 747 of the Public Health Service Act ( 42 U.S.C. 293k ) is amended— (1) in subsection (b)(3)(E), by striking vulnerable populations and inserting individuals with a mental illness or substance use disorder or other vulnerable populations, ; and (2) in subsection (c)— (A) in paragraph (1), 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 2017 through 2021. ; and (B) in paragraph (3), by striking 2010 through 2014 and inserting 2017 through 2021 . 302. Reauthorization of 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 $125,000,000 for each of the fiscal years 2010 through 2014 and inserting $40,000,000 for each of fiscal years 2017 through 2021 . IV Supporting emerging professions 401. Authorizing appropriations for Quentin N. Burdick program for rural interdisciplinary training Section 754 of the Public Health Service Act ( 42 U.S.C. 794d ) is amended by adding at the end the following: (e) Authorization of appropriations There are authorized to be appropriated $10,000,000 for each of fiscal years 2017 through 2021 to carry out this section. . 402. Dental therapists (a) Training in general, pediatric, and public health dentistry Section 748 of the Public Health Service Act ( 42 U.S.C. 293k–2 ) is amended— (1) in subsection (a)(1)— (A) in subparagraph (A), by inserting dental therapists, after practicing dentists, ; and (B) in subparagraph (B), by inserting dental therapists, after practicing dentists, ; and (2) in subsection (b)— (A) by striking programs in dental or dental hygiene and inserting programs in dental, dental therapy, or dental hygiene ; and (B) by striking dental students, residents, and dental hygiene students and inserting dental students, residents, dental therapy students, and dental hygiene students . (b) Funding for primary dental demonstration program (1) Timeframe Section 340G–1(b) of the Public Health Service Act ( 42 U.S.C. 256g–1(b) ) is amended— (A) by striking 2 years and inserting 10 years ; and (B) by striking 7 years and inserting 14 years . (2) Sense of Senate It is the sense of the Senate that— (A) section 340G–1 of the Public Health Service Act ( 42 U.S.C. 256g–1 ) should be fully funded for each of fiscal years 2017 through 2021; and (B) any appropriations Act appropriating amounts for fiscal year 2017, or any subsequent fiscal year through fiscal year 2021, should not contain any language prohibiting the availability of funds for such section. 403. Allied health professionals (a) Definition of allied health professionals Section 799B(5) of the Public Health Service Act ( 42 U.S.C. 295p(5) ) is amended— (1) in subparagraph (B)(v), by striking ; and and inserting , including services related to managing the implementation and operation of health information technology; ; (2) in subparagraph (C), by striking the period and inserting ; and ; and (3) by adding at the end the following: (D) who may be licensed or certified to practice in an emerging health care profession as defined by the Secretary, which may include community paramedics, dental therapists, doulas, and other community health workers. . (b) Loan forgiveness for allied health professionals Section 428K(h) of the Higher Education Act of 1965 ( 20 U.S.C. 1078–11(h) ) is amended— (1) by striking this section such sums and inserting this section— (1) such sums ; (2) by striking the period and inserting ; and ; and (3) by adding at the end the following: (2) such sums as may be necessary for each of fiscal years 2017 through 2021 to provide loan forgiveness in accordance with this section for individuals meeting the requirements of subsection (b)(18). . (c) Training for mid-Career public and allied health professionals Section 777 of the Public Health Service Act ( 42 U.S.C. 295f–2 ) is amended— (1) in subsection (b)(2), by inserting , including individuals who are foreign-trained health professionals before the period; (2) by redesignating subsection (c) as subsection (d); (3) by inserting after subsection (b) the following: (c) Preference (1) Eligible institutions In making grants under this section, the Secretary shall prioritize awarding grants to eligible entities located in rural or underserved areas. (2) Eligible individuals In awarding scholarships to eligible individuals under this section, an eligible entity shall prioritize individuals from rural or underserved communities. ; and (4) in subsection (d), as so redesignated, by striking 2015 and inserting 2021 . 404. Community health workers Section 399V of the Public Health Service Act ( 42 U.S.C. 280g–11 ) is amended— (1) in subsection (b)— (A) in paragraph (4), by striking ; or ; (B) in paragraph (5), by striking the period and inserting ; or ; and (C) by adding at the end the following: (6) to educate, guide, and provide assistance with patients enrolled in patient-centered medical homes, accountable care organizations (as such term is used in section 1899 of the Social Security Act), other State certified medical or health care homes, or other coordinated care models. ; and (2) in subsection (d)(1)— (A) in subparagraph (B), by striking or after the semicolon; (B) in subparagraph (C), by inserting or after the semicolon; and (C) by adding at the end the following: (D) that meet the requirements of subparagraph (A), (B), or (C) and are designated as a health professional shortage area under section 332(a); . 405. GAO report (a) In general Not later than 2 years after the date of enactment of this Act, the Comptroller General of the United States shall prepare and submit to Congress a report on emerging health care professions as defined by the Secretary of Health and Human Services. (b) Contents The report prepared under subsection (a) shall include recommendations on— (1) improving data collection with respect to emerging health care professions, such as community health workers, community paramedics, and dental therapists; (2) establishing a systematic way for Federal officials to track State financing and use of community health workers, community paramedics, and dental therapists; (3) improving methodologies to calculate the return on investment associated with supporting emerging health care professions and the impact of such professions on health care quality; (4) standards for certification and training of individuals in emerging health care professions; (5) establishing a process to ensure that the Secretary of Health and Human Services continually— (A) assesses emerging health care professions for quality and consistency; and (B) recognizes and incorporates these professions in health care delivery; and (6) establishing a centralized source for evidence on emerging health care professions to facilitate the establishment of best practices for expanded use of emerging health care professions. V Mental health workforce 501. Establishing mental health and substance use disorder curriculum (a) In general Subpart I of part C of title VII of the Public Health Service Act ( 42 U.S.C. 293K et seq. ) is amended by inserting after section 747A the following: 747B. Establishing mental health and substance use disorder curriculum (a) Support and development of mental health and substance use disorder training programs (1) In general The Secretary may make grants to, or enter into contracts with, a school of medicine or osteopathic medicine, a nursing school, a physician assistant training program, a school of pharmacy, a school of social work, an accredited public or nonprofit private hospital, or a public or private nonprofit entity which the Secretary has determined is capable of carrying out such grant or contract to establish, maintain, or improve— (A) academic units or programs that include content and clinical experiences related to mental health and substance use disorder fields, with a special focus on addiction; (B) programs that enhance interdisciplinary recruitment, training, and faculty development for the purposes of improving clinical teaching and research in mental health and substance use disorder fields, including addiction; (C) programs that develop, assess, and disseminate evidence-based practices for the design of academic units, training programs, and faculty development initiatives in mental health and substance use disorder fields, including addiction; and (D) recommendations for medical education curriculum content standards regarding mental health and substance use disorders, including addiction, to ensure that students are able to recognize, diagnose, and treat mental health and substance use disorders. (2) Partnership required To be eligible to receive a grant or contract under paragraph (1), an entity shall enter into a partnership with a medical education accrediting organization (such as the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, the Commission on Osteopathic College Accreditation, the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, the Accreditation Council for Pharmacy Education, the Council on Social Work Education, or the Accreditation Review Commission on Education for the Physician Assistant). (b) Preference in making awards under this section In making awards of grants and contracts under subsection (a), the Secretary shall give preference to any qualified applicant for such an award that agrees to expend the award for the purpose of— (1) establishing academic units or programs in mental health and substance use disorder fields, including addiction medicine; or (2) substantially expanding such units or programs. (c) Priorities in making awards In awarding grants or contracts under subsection (a), the Secretary shall give priority to qualified applicants that— (1) have a record of training the greatest percentage of mental health and substance use disorder providers, including addiction providers, who enter and remain in mental health and substance use disorder fields; (2) have a record of training the greatest percentage of providers, or that have demonstrated significant improvements in the percentage of providers trained, who enter and remain in settings with integrated primary and mental health and substance use disorder health care service, or have a record of establishing multidisciplinary addiction medicine fellowship training programs; (3) have a record of training individuals who are from underrepresented minority groups, including native populations, or from a rural or disadvantaged background; (4) provide training in the care of rural and vulnerable populations, such as children, pregnant and post-partum women, older adults, homeless individuals, victims of trafficking, victims of abuse or trauma, and other groups as defined by the Secretary; (5) teach trainees the skills to provide interprofessional, integrated care through collaboration among health professionals; or (6) provide training in cultural competency and health literacy. (d) Duration of awards The period during which payments are made to an entity from an award of a grant or contract under this section shall be 5 years. (e) Authorization of appropriations For purposes of carrying out this section, there are authorized to be appropriated such sums as may be necessary for each of fiscal years 2017 through 2021. . (b) Increasing transparency regarding graduate medical education on mental health and substance use disorders Not later than 5 years after the date of the enactment of this Act, and annually thereafter, the Secretary of Health and Human Services shall submit to Congress a report that describes the activities that hospitals receiving funding under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) have underway to promote interdisciplinary care teams and provide training for all medical residents, medical students, and faculty in mental health and substance use disorders, including addiction medicine. 502. Streamlining mental and behavioral health workforce programs (a) In general Part D of title VII of the Public Health Service Act ( 42 U.S.C. 294 et seq. ) is amended— (1) by striking sections 755 ( 42 U.S.C. 294e ) and 756 ( 42 U.S.C. 294e–1 ); (2) by redesignating sections 757 ( 42 U.S.C. 294f ) and 759 ( 42 U.S.C. 294i ) as sections 756 and 757, respectively; and (3) by inserting after section 754 the following: 755. Mental and behavioral health education and training grants (a) Grants authorized The Secretary may award grants to eligible institutions of higher education to support the recruitment of students for, and education and clinical experience of the students in— (1) accredited institutions of higher education or accredited professional training programs that are establishing or expanding internships or other field placement programs in mental health in psychiatry, psychology, school psychology, behavioral pediatrics, psychiatric nursing, social work, school social work, substance use disorder prevention and treatment, marriage and family therapy, occupational therapy, school counseling, or professional counseling, including such internships or programs with a focus on child and adolescent mental health and transitional-age youth; (2) accredited doctoral, internship, and post-doctoral residency programs of health service psychology, including clinical psychology, counseling, and school psychology, for the development and implementation of interdisciplinary training of psychology graduate students for providing behavioral and mental health services, including substance use disorder prevention and treatment services, and the development of faculty in health service psychology; (3) accredited master’s and doctoral degree programs of social work for the development and implementation of interdisciplinary training of social work graduate students for providing behavioral and mental health services, including substance use disorder prevention and treatment services, and the development of faculty in social work; or (4) State-licensed mental health nonprofit and for-profit organizations to enable such organizations to pay for programs for preservice or in-service training in a behavioral health-related paraprofessional field with preference for preservice or in-service training of paraprofessional child and adolescent mental health workers. (b) Eligibility requirements To be eligible for a grant under this section, an institution of higher education shall demonstrate— (1) an ability to recruit and place the students described in subsection (a) in areas with a high need and high demand population or rural or underserved areas; (2) that individuals and groups from different racial, ethnic, cultural, geographic, religious, linguistic, and class backgrounds, and different genders and sexual orientations, participate in the programs of the institution; (3) knowledge and understanding of the concerns of the individuals and groups described in paragraph (2), especially individuals with mental health symptoms or diagnoses, particularly children and adolescents, and transitional-age youth; (4) that any internship or other field placement program assisted through the grant will prioritize cultural and linguistic competency; and (5) that the institution of higher education will provide to the Secretary such data, assurances, and information as the Secretary may require. (c) Institutional requirement For grants awarded under paragraphs (2) and (3) of subsection (a), at least 4 of the grant recipients shall be historically black colleges or universities or other minority-serving institutions. (d) Priority In selecting grant recipients, the Secretary shall give priority to— (1) for grants awarded under paragraphs (1), (2), and (3) of subsection (a), programs that have demonstrated the ability to train psychology and social work professionals to work in integrated care settings; (2) for a grant under subsection (a)(4), programs for paraprofessionals that emphasize the role of the family and the lived experience of the consumer and family-paraprofessional partnerships; and (3) programs with a record of training individuals from rural and underserved communities and placing graduates in these communities. (e) Report to Congress Not later than 2 years after the date of enactment of the Strengthening Our Rural Health Workforce Act of 2016 , and annually thereafter, the Secretary shall submit to Congress a report on the effectiveness of the grants under this section in— (1) providing graduate students support for experiential training (internship or field placement); (2) recruiting of students interested in behavioral health practice; (3) developing and implementing interprofessional training and integration within primary care; (4) developing and implementing accredited field placements and internships; and (5) collecting data on the number of students trained in mental health and the number of available accredited internships and field placements. (f) Authorization of appropriation There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2017 through 2021. . (b) Conforming amendments The Public Health Service Act ( 42 U.S.C. 201 et seq. ), as amended by subsection (a), is further amended— (1) in section 338A(d)(2)(A) ( 42 U.S.C. 254l(d)(2)(A) ), by striking or under section 758 ; (2) in section 756(b)(2) ( 42 U.S.C. 294f(b)(2) ), as so redesignated, by striking , 753(b), and 755(b) and inserting and 753(b) ; and (3) in section 761 ( 42 U.S.C. 294n )— (A) in subsection (b)(2)(E), by striking 757(d)(3) and inserting 756(d)(3) ; (B) in subsection (d)(2)(B), by striking 757(d)(3) and inserting 756(d)(3) ; and (C) in subsection (d)(3), by striking 757(d)(4) and inserting 756(d)(4) .