II Calendar No. 285 116th CONGRESS 1st Session S. 1399 IN THE SENATE OF THE UNITED STATES May 9, 2019 Mr. Merkley (for himself, Mr. Burr , Ms. Baldwin , Mrs. Blackburn , Mr. Jones , and Ms. Collins ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions November 5, 2019 Reported by Mr. Alexander , with an amendment Strike out all after the enacting clause and insert the part printed in italic A BILL To amend title VIII of the Public Health Services Act to revise and extend nursing workforce development programs.

1. Short title This Act may be cited as the Title VIII Nursing Workforce Reauthorization Act of 2019 . 2. Nursing workforce development (a) In general Title VIII of the Public Health Service Act ( 42 U.S.C. 296 et seq.) is amended— (1) in section 801 ( 42 U.S.C. 296 ), by adding at the end the following: (18) Nurse managed health clinic The term nurse managed health clinic means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency. ; (2) in section 802(c) ( 42 U.S.C. 296a(c) ), by inserting , and how such project aligns with the goals in section 806(a) before the period in the second sentence; (3) in section 803(b) ( 42 U.S.C. 296b(b) ), by adding at the end the following: Such Federal funds are intended to supplement, not supplant, existing non-Federal expenditures for such activities. ; (4) in section 806 ( 42 U.S.C. 296e )— (A) in subsection (a), by striking as needed to and all that follows and inserting the following: “as needed to address national nursing needs, including— (1) addressing challenges, including through supporting training and education of nursing students, related to the distribution of the nursing workforce and existing or projected nursing workforce shortages in geographic areas that have been identified as having, or that are projected to have, a nursing shortage; (2) increasing access to and the quality of health care services, including by supporting the training of professional registered nurses, advanced practice registered nurses, and advanced education nurses within community based settings and in a variety of health delivery system settings; or (3) addressing the strategic goals and priorities identified by the Secretary and that are in accordance with this title. Contracts may be entered into under this title with public or private entities as determined necessary by the Secretary. ; (B) in subsection (b)(2), by striking a demonstration and all that follows and inserting the following: the reporting of data and information demonstrating that satisfactory progress has been made by the program or project in meeting the performance outcome standards (as described in section 802) of such program or project. ; (C) in subsection (e)(2), by inserting , and have relevant expertise and experience before the period at the end of the first sentence; and (D) by adding at the end the following: (i) Biennial report on nursing workforce program improvements Not later than September 30, 2020, and biennially thereafter, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, a report that contains an assessment of the programs and activities of the Department of Health and Human Services related to enhancing the nursing workforce, including the extent to which programs and activities under this title meet the identified goals and performance measures developed for the respective programs and activities, and the extent to which the Department coordinates with other Federal departments with programs designed to improve the nursing workforce. ; (5) in section 811 ( 42 U.S.C. 296j )— (A) in subsection (b)— (i) by striking Master's and inserting graduate ; and (ii) by inserting clinical nurse leaders, after nurse administrators, ; (B) by redesignating subsections (f) and (g) as subsections (g) and (h), respectively; and (C) by inserting after subsection (e), the following: (f) Authorized clinical nurse specialist programs Clinical nurse specialist programs eligible for support under this section are education programs that— (1) provide registered nurses with full-time clinical nurse specialist education; and (2) have as their objective the education of clinical nurse specialists who will, upon completion of such a program, be qualified to effectively provide care through the wellness and illness continuum to inpatients and outpatients experiencing acute and chronic illness. ; (6) in section 831 ( 42 U.S.C. 296p )— (A) in the section heading, by striking and quality grants and inserting quality, and retention grants ; (B) in subsection (b)(2), by striking other high-risk groups such as the elderly, individuals with HIV/AIDS, substance abusers, the homeless, and victims and inserting high risk groups, such as the elderly, individuals with HIV/AIDS, individuals with mental health or substance use disorders, individuals who are homeless, and survivors ; (C) in subsection (c)(1)— (i) in subparagraph (A)— (I) by striking advancement for nursing personnel and inserting the following: “advancement for— (i) nursing ; (II) by striking professional nurses, advanced education nurses, licensed practical nurses, certified nurse assistants, and home health aides and inserting professional registered nurses, advanced practice registered nurses, and nurses with graduate nursing education ; and (III) by adding at the end the following: (ii) individuals including licensed practical nurses, licensed vocational nurses, certified nurse assistants, home health aides, diploma degree or associate degree nurses, to become registered nurses with baccalaureate degrees or nurses with graduate nursing education; ; (ii) in subparagraph (B), by striking the period and inserting ; and ; and (iii) by adding at the end the following: (C) developing and implementing internships, accredited fellowships, and accredited residency programs in collaboration with one or more accredited schools of nursing, to encourage the mentoring and development of specialties. ; (D) by striking subsection (e); (E) by redesignating subsection (f) through (h), as subsections (e) through (g), respectively; (F) in subsection (e) (as so redesignated), by striking The Secretary shall submit to the Congress before the end of each fiscal year and inserting As part of the report on nursing workforce programs described in section 806(i), the Secretary shall include ; (G) in subsection (f) (as so redesignated), by striking a school of nursing, as defined in section 801(2),, and inserting an accredited school of nursing, as defined in section 801(2), a health care facility, including federally qualified health centers or nurse-managed health clinics, or a partnership of such a school and facility ; and (H) in subsection (g) (as so redesignated), by striking 2010 through 2014 and inserting 2020 through 2024 ; (7) by striking section 831A ( 42 U.S.C. 296p–1 ); (8) in section 846 ( 42 U.S.C. 297n )— (A) by striking the last sentence of subsection (a); (B) in subsection (b)(1), by striking he began such practice and inserting the individual began such practice ; and (C) in subsection (i)(I), by striking 2003 through 2007 and inserting 2020 through 2024 ; (9) in section 846A(f) ( 42 U.S.C. 247n–1(f) ), by striking 2010 through 2014 and inserting 2020 through 2024 ; (10) in section 847(g) ( 42 U.S.C. 297o(g) ), by striking such sums as may be necessary for each of fiscal years 2010 through 2014 and inserting $115,635,000 for each of fiscal years 2020 through 2024 ; (11) in section 851 ( 42 U.S.C. 297t )— (A) in subsection (b)(1)(A)(iv), by striking and nurse anesthetists and inserting nurse anesthetists, and clinical nurse specialists ; (B) in subsection (d)(3)— (i) by striking 3 years after the date of enactment of this section and inserting 2 years after the date of enactment of the Title VIII Nursing Workforce Reauthorization Act ; (ii) by striking Labor and Human Resources and inserting Health, Education, Labor, and Pensions ; and (iii) by inserting Energy and before Commerce ; and (C) in subsection (g), by striking under this title and inserting for carrying out parts B, C, and D ; (12) in section 865(e) ( 42 U.S.C. 298(e) ), by striking 2014 and inserting 2024 ; and (13) in section 871 ( 42 U.S.C. 298d ), by striking $338,000,000 for fiscal year 2010, and such sums as may be necessary for each of the fiscal years 2011 through 2016 and inserting $133,837,000 for each of fiscal years 2020 through 2024 . (b) Evaluation and report on nurse loan repayment programs (1) Evaluation The Comptroller General shall conduct an evaluation of the nurse loan repayment programs administered by the Health Resources and Services Administration. Such evaluation shall include— (A) the manner in which payments are made under such programs; (B) the existing oversight functions necessary to ensure the proper use of such programs, including payments made as part of such programs; (C) the identification of gaps, if any, in oversight functions; and (D) information on the number of nurses assigned to facilities pursuant to such programs, including the type of facility to which nurses are assigned and the impact of modifying the eligibility requirements for programs under section 846 of the Public Health Service Act ( 42 U.S.C. 297n ), such as the impact on entities to which nurses had previously been assigned prior to fiscal year 2019 (such as federally qualified health centers and facilities affiliated with the Indian Health Service). (2) Report Not later than 18 months after the enactment of this Act, the Comptroller General shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report on the evaluation under paragraph (1), which may include recommendations to improve relevant nursing workforce loan repayment programs.

1. Short title This Act may be cited as the Title VIII Nursing Workforce Reauthorization Act of 2019 . 2. Nursing workforce development (a) In general Title VIII of the Public Health Service Act ( 42 U.S.C. 296 et seq.) is amended— (1) in section 801 ( 42 U.S.C. 296 ), by adding at the end the following: (18) Nurse managed health clinic The term nurse managed health clinic means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency. ; (2) in section 802(c) ( 42 U.S.C. 296a(c) ), by inserting , and how such project aligns with the goals in section 806(a) before the period in the second sentence; (3) in section 803(b) ( 42 U.S.C. 296b(b) ), by adding at the end the following: Such Federal funds are intended to supplement, not supplant, existing non-Federal expenditures for such activities. ; (4) in section 806 ( 42 U.S.C. 296e )— (A) in subsection (a), by striking as needed to and all that follows and inserting the following: “as needed to address national nursing needs, including— (1) addressing challenges, including through supporting training and education of nursing students, related to the distribution of the nursing workforce and existing or projected nursing workforce shortages in geographic areas that have been identified as having, or that are projected to have, a nursing shortage; (2) increasing access to and the quality of health care services, including by supporting the training of professional registered nurses, advanced practice registered nurses, and advanced education nurses within community based settings and in a variety of health delivery system settings; or (3) addressing the strategic goals and priorities identified by the Secretary and that are in accordance with this title. Contracts may be entered into under this title with public or private entities as determined necessary by the Secretary. ; (B) in subsection (b)(2), by striking a demonstration and all that follows and inserting the following: the reporting of data and information demonstrating that satisfactory progress has been made by the program or project in meeting the performance outcome standards (as described in section 802) of such program or project. ; (C) in subsection (e)(2), by inserting , and have relevant expertise and experience before the period at the end of the first sentence; and (D) by adding at the end the following: (i) Biennial report on nursing workforce program improvements Not later than September 30, 2020, and biennially thereafter, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, a report that contains an assessment of the programs and activities of the Department of Health and Human Services related to enhancing the nursing workforce, including the extent to which programs and activities under this title meet the identified goals and performance measures developed for the respective programs and activities, and the extent to which the Department coordinates with other Federal departments regarding programs designed to improve the nursing workforce. ; (5) in section 811 ( 42 U.S.C. 296j )— (A) in subsection (b)— (i) by striking Master's and inserting graduate ; and (ii) by inserting clinical nurse leaders, after nurse administrators, ; (B) by redesignating subsections (f) and (g) as subsections (g) and (h), respectively; and (C) by inserting after subsection (e), the following: (f) Authorized clinical nurse specialist programs Clinical nurse specialist programs eligible for support under this section are education programs that— (1) provide registered nurses with full-time clinical nurse specialist education; and (2) have as their objective the education of clinical nurse specialists who will, upon completion of such a program, be qualified to effectively provide care through the wellness and illness continuum to inpatients and outpatients experiencing acute and chronic illness. ; and (6) in section 831 ( 42 U.S.C. 296p )— (A) in the section heading, by striking and quality grants and inserting quality, and retention grants ; (B) in subsection (b)(2), by striking other high-risk groups such as the elderly, individuals with HIV/AIDS, substance abusers, the homeless, and victims and inserting high risk groups, such as the elderly, individuals with HIV/AIDS, individuals with mental health or substance use disorders, individuals who are homeless, and survivors ; (C) in subsection (c)(1)— (i) in subparagraph (A)— (I) by striking advancement for nursing personnel and inserting the following: “advancement for— (i) nursing ; (II) by striking professional nurses, advanced education nurses, licensed practical nurses, certified nurse assistants, and home health aides and inserting professional registered nurses, advanced practice registered nurses, and nurses with graduate nursing education ; and (III) by adding at the end the following: (ii) individuals including licensed practical nurses, licensed vocational nurses, certified nurse assistants, home health aides, diploma degree or associate degree nurses, and other health professionals, such as health aides or community health practitioners certified under the Community Health Aide Program of the Indian Health Service, to become registered nurses with baccalaureate degrees or nurses with graduate nursing education; ; (ii) in subparagraph (B), by striking the period and inserting ; and ; and (iii) by adding at the end the following: (C) developing and implementing internships, accredited fellowships, and accredited residency programs in collaboration with one or more accredited schools of nursing, to encourage the mentoring and development of specialties. ; (D) by striking subsection (e); (E) by redesignating subsection (f) through (h), as subsections (e) through (g), respectively; (F) in subsection (e) (as so redesignated), by striking The Secretary shall submit to the Congress before the end of each fiscal year and inserting As part of the report on nursing workforce programs described in section 806(i), the Secretary shall include ; (G) in subsection (f) (as so redesignated), by striking a school of nursing, as defined in section 801(2),, and inserting an accredited school of nursing, as defined in section 801(2), a health care facility, including federally qualified health centers or nurse-managed health clinics, or a partnership of such a school and facility ; and (H) in subsection (g) (as so redesignated), by striking 2010 through 2014 and inserting 2020 through 2024 ; (7) by striking section 831A ( 42 U.S.C. 296p-1 ); (8) in section 846 ( 42 U.S.C. 297n )— (A) by striking the last sentence of subsection (a); (B) in subsection (b)(1), by striking he began such practice and inserting the individual began such practice ; and (C) in subsection (i)(I), by striking 2003 through 2007 and inserting 2020 through 2024 ; (9) in section 846A(f) ( 42 U.S.C. 247n-1(f) ), by striking 2010 through 2014 and inserting 2020 through 2024 ; (10) in section 847(g) ( 42 U.S.C. 297o(g) ), by striking such sums as may be necessary for each of fiscal years 2010 through 2014 and inserting $115,635,000 for each of fiscal years 2020 through 2024 ; (11) in section 851 ( 42 U.S.C. 297t )— (A) in subsection (b)(1)(A)(iv), by striking and nurse anesthetists and inserting nurse anesthetists, and clinical nurse specialists ; (B) in subsection (d)(3)— (i) by striking 3 years after the date of enactment of this section and inserting 2 years after the date of enactment of the Title VIII Nursing Reauthorization Act ; (ii) by striking Labor and Human Resources and inserting Health, Education, Labor, and Pensions ; and (iii) by inserting Energy and before Commerce ; and (C) in subsection (g), by striking under this title and inserting for carrying out parts B, C, and D ; (12) by striking sections 861 and 862 ( 42 U.S.C. 297w and 297x); (13) in section 865(e) ( 42 U.S.C. 298(e) ), by striking 2014 and inserting 2024 ; and (14) in section 871 ( 42 U.S.C. 298d ), by striking $338,000,000 for fiscal year 2010, and such sums as may be necessary for each of the fiscal years 2011 through 2016 and inserting $133,837,000 for each of fiscal years 2020 through 2024 . (b) Evaluation and report on nurse loan repayment programs (1) Evaluation The Comptroller General shall conduct an evaluation of the nurse loan repayment programs administered by the Health Resources and Services Administration. Such evaluation shall include— (A) the manner in which payments are made under such programs; (B) the existing oversight functions necessary to ensure the proper use of such programs, including payments made as part of such programs; (C) the identification of gaps, if any, in oversight functions; and (D) information on the number of nurses assigned to facilities pursuant to such programs, including the type of facility to which nurses are assigned and the impact of modifying the eligibility requirements for programs under section 846 of the Public Health Service Act ( 42 U.S.C. 297n ), such as the impact on entities to which nurses had previously been assigned prior to fiscal year 2019 (such as federally qualified health centers and facilities affiliated with the Indian Health Service). (2) Report Not later than 18 months after the enactment of this Act, the Comptroller General shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives, a report on the evaluation under paragraph (1), which may include recommendations to improve relevant nursing workforce loan repayment programs.

November 5, 2019 Reported with an amendment