II 118th CONGRESS 1st Session S. 3449 IN THE SENATE OF THE UNITED STATES December 7, 2023 Mr. Heinrich (for himself, Mr. Wyden , Ms. Klobuchar , Mr. Murphy , Mr. Luján , Mr. Blumenthal , and Ms. Cortez Masto ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To provide low-income individuals with opportunities to enter and follow a career pathway in the health professions, and for other purposes.

1. Short title This section may be cited as the Pathways to Health Careers Act . 2. Career pathways through health profession opportunity grants Effective October 1, 2023, section 2008 of the Social Security Act ( 42 U.S.C. 1397g ) is amended to read as follows: 2008. Career pathways through health profession opportunity grants (a) Application requirements An eligible entity desiring a grant under this section for a project shall submit to the Secretary an application for the grant, that includes the following: (1) A description of how the applicant will use a career pathways approach to train eligible individuals for health professions that pay well or will put eligible individuals on a career path to an occupation that pays well, under the project. (2) A description of the adult basic education and literacy activities, work readiness activities, training activities, and case management and career coaching services that the applicant will use to assist eligible individuals to gain work experience, connection to employers, and job placement, and a description of the plan for recruiting, hiring, and training staff to provide the case management, mentoring, and career coaching services, under the project directly or through local governmental, apprenticeship, educational, or charitable institutions. (3) In the case of an application for a grant under this section for a demonstration project described in subsection (c)(2)(B)(i)(I)— (A) a demonstration that the State in which the demonstration project is to be conducted has in effect policies or laws that permit certain allied health and behavioral health care credentials to be awarded to people with certain arrest or conviction records (which policies or laws shall include appeals processes, waivers, certificates, and other opportunities to demonstrate rehabilitation to obtain credentials, licensure, and approval to work in the proposed health careers), and a plan described in the application that will use a career pathway to assist participants with such a record in acquiring credentials, licensing, and employment in the specified careers; (B) a discussion of how the project or future strategic hiring decisions will demonstrate the experience and expertise of the project in working with job seekers who have arrest or conviction records or employers with experience working with people with arrest or conviction records; (C) an identification of promising innovations or best practices that can be used to provide the training; (D) a proof of concept or demonstration that the applicant has done sufficient research on workforce shortage or in-demand jobs for which people with certain types of arrest or conviction records can be hired; (E) a plan for recruiting students who are eligible individuals into the project; and (F) a plan for providing post-employment support and ongoing training as part of a career pathway under the project. (4) In the case of an application for a grant under this section for a demonstration project described in subsection (c)(2)(B)(i)(II)— (A) a description of the partnerships, strategic staff hiring decisions, tailored program activities, or other programmatic elements of the project, such as training plans for doulas and other community health workers and training plans for midwives and other allied health professions, that are designed to support a career pathway in pregnancy, birth, or post-partum services; and (B) a demonstration that the State in which the demonstration project is to be conducted recognizes doulas or midwives, as the case may be. (5) A demonstration that the applicant has experience working with low-income populations, or a description of the plan of the applicant to work with a partner organization that has the experience. (6) A plan for providing post-employment support and ongoing training as part of a career pathway under the project. (7) A description of the support services that the applicant will provide under the project, including a plan for how child care and transportation support services will be guaranteed and, if the applicant will provide a cash stipend or wage supplement, how the stipend or supplement would be calculated and distributed. (8) A certification by the applicant that the project development included— (A) consultation with a local workforce development board established under section 107 of the Workforce Innovation and Opportunity Act; (B) consideration of apprenticeship and pre-apprenticeship models registered under the Act of August 16, 1937 (also known as the National Apprenticeship Act ); (C) consideration of career pathway programs in the State in which the project is to be conducted; and (D) a review of the State plan under section 102 or 103 of the Workforce Innovation and Opportunity Act. (9) A description of the availability and relevance of recent labor market information and other pertinent evidence of in-demand jobs or worker shortages. (10) A certification that the applicant will directly provide or contract for the training services described in the application. (11) A commitment by the applicant that, if the grant is made to the applicant, the applicant will— (A) during the planning period for the project, provide the Secretary with any information needed by the Secretary to establish adequate data reporting and administrative structure for the project; (B) hire a person to direct the project not later than the end of the planning period applicable to the project; (C) accept all technical assistance offered by the Secretary with respect to the grant; (D) participate in peer technical assistance conferences as are regularly scheduled by the Secretary; and (E) provide all data required by the Secretary under subsection (g). (b) Preferences in considering applications In considering applications for a grant under this section, the Secretary shall give preference to— (1) applications submitted by applicants to whom a grant was made under this section or any predecessor to this section; (2) applications submitted by applicants who have business and community partners in each of the following categories: (A) State and local government agencies and social service providers, including a State or local entity that administers a State program funded under part A of this title; (B) institutions of higher education, apprenticeship programs, and local workforce development boards established under section 107 of the Workforce Innovation and Opportunity Act; and (C) health care employers, health care industry or sector partnerships, labor unions, and labor-management partnerships; (3) applications that include opportunities for mentoring or peer support, and make career coaching available, as part of the case management plan; (4) applications which describe a project that will serve a rural area in which— (A) the community in which the individuals to be enrolled in the project reside is located; (B) the project will be conducted; or (C) an employer partnership that has committed to hiring individuals who successfully complete all activities under the project is located; (5) applications that include a commitment to providing project participants with a cash stipend or wage supplement; and (6) applications which have an emergency cash fund to assist project participants financially in emergency situations. (c) Grants (1) Competitive grants (A) Grant authority (i) In general The Secretary, in consultation with the Secretary of Labor and the Secretary of Education, may make a grant in accordance with this paragraph to an eligible entity whose application for the grant is approved by the Secretary, to conduct a project designed to train low-income individuals for allied health professions, health information technology, physicians assistants, nursing assistants, registered nurse, advanced practice nurse, emergency medical technicians, paramedics, and other professions considered part of a health care career pathway model. (ii) Guarantee of grantees in each state and the district of columbia For each grant cycle, the Secretary shall award a grant under this paragraph to at least 2 eligible entities in each State that is not a territory, to the extent there are a sufficient number of applications submitted by the entities that meet the requirements applicable with respect to such a grant. If, for a grant cycle, there are fewer than 2 such eligible entities in a State, the Secretary shall include that information in the report required by subsection (g)(2) that covers the fiscal year. (B) Guarantee of grants for indian populations From the amount reserved under subsection (i)(2)(B) for each fiscal year, the Secretary shall award a grant under this paragraph to at least 10 eligible entities that are an Indian tribe, a tribal organization, or a tribal college or university, to the extent there are a sufficient number of applications submitted by the entities that meet the requirements applicable with respect to such a grant. (C) Guarantee of grantees in the territories From the amount reserved under subsection (i)(2)(C) for each fiscal year, the Secretary shall award a grant under this paragraph to at least 2 eligible entities that are located in a territory, to the extent there are a sufficient number of applications submitted by the entities that meet the requirements applicable with respect to such a grant. (2) Grants for demonstration projects (A) Grant authority The Secretary, in consultation with the Secretary of Labor and the Secretary of Education (and, with respect to demonstration projects of the type described in subparagraph (B)(i)(I), the Attorney General) shall make a grant in accordance with this subsection to an eligible entity whose application for the grant is approved by the Secretary, to conduct a demonstration project that meets the requirements of subparagraph (B). (B) Requirements The requirements of this subparagraph are the following: (i) Type of project The demonstration project shall be of 1 of the following types: (I) Individuals with arrest or conviction records demonstration The demonstration project shall be of a type designed to provide education and training for eligible individuals with arrest or conviction records to enter and follow a career pathway in the health professions through occupations that pay well and are expected to experience a labor shortage or be in high demand. (II) Maternal mortality career pathway demonstration The demonstration project shall be of a type designed to provide education and training for eligible individuals to enter and follow a career pathway in the field of pregnancy, childbirth, and post-partum, in a State that recognizes doulas or midwives and that provides payment for services provided by doulas or midwives, as the case may be, under private or public health insurance plans. (ii) Duration The demonstration project shall be conducted for not less than 5 years. (C) Minimum allocation of funds for each type of demonstration project (i) Individuals with arrest or conviction records demonstrations Not less than 25 percent of the amounts made available for grants under this paragraph shall be used to make grants for demonstration projects of the type described in subparagraph (B)(i)(I). (ii) Maternal mortality career pathway demonstrations Not less than 25 percent of the amounts made available for grants under this paragraph shall be used to make grants for demonstration projects of the type described in subparagraph (B)(i)(II). (3) Grant cycle The grant cycle under this section shall be not less than 5 years, with a planning period of not more than the 1st 12 months of the grant cycle. During the planning period, the amount of the grant shall be in such lesser amount as the Secretary determines appropriate. (d) Use of grant (1) In general An entity to which a grant is made under this section shall use the grant in accordance with the approved application for the grant. (2) Support to be provided (A) Required support A project for which a grant is made under this section shall include the following: (i) An assessment for adult basic skill competency, and provision of adult basic skills education if necessary for lower-skilled eligible individuals to enroll in the project and go on to enter and complete post-secondary training, through means including the following: (I) Establishing a network of partners that offer pre-training activities for project participants who need to improve basic academic skills or English language proficiency before entering a health occupational training career pathway program. (II) Offering resources to enable project participants to continue advancing adult basic skill proficiency while enrolled in a career pathway program. (III) Embedding adult basic skill maintenance as part of ongoing post-graduation career coaching and mentoring. (ii) A guarantee that child care is an available and affordable support service for project participants through means such as the following: (I) Referral to, and assistance with, enrollment in a subsidized child care program. (II) Direct payment to a child care provider if a slot in a subsidized child care program is not available or reasonably accessible. (III) Payment of co-payments or associated fees for child care. (iii) Case management plans that include career coaching (with the option to offer appropriate peer support and mentoring opportunities to help develop soft skills and social capital), which may be offered on an ongoing basis before, during, and after initial training as part of a career pathway model. (iv) A plan to provide project participants with transportation through means such as the following: (I) Referral to, and assistance with enrollment in, a subsidized transportation program. (II) If a subsidized transportation program is not reasonably available, direct payments to subsidize transportation costs. (v) In the case of a demonstration project of the type described in subsection (c)(2)(B)(i)(I), access to legal assistance for project participants for the purpose of addressing arrest or conviction records and associated workforce barriers. (B) Allowed support The goods and services provided under a project for which a grant is made under this section may include the following: (i) A cash stipend. (ii) A reserve fund for financial assistance to project participants in emergency situations. (iii) Tuition, and training materials such as books, software, uniforms, shoes, and hair nets, and personal protective equipment. (iv) In-kind resource donations such as interview clothing and conference attendance fees. (v) Assistance with accessing and completing high school equivalency or adult basic education courses as necessary to achieve success in the project and make progress toward career goals. (vi) Assistance with programs and activities, including legal assistance, deemed necessary to address arrest or conviction records as an employment barrier. (vii) Other support services as deemed necessary for family well-being, success in the project, and progress toward career goals. (3) Training A project for which a grant is made under this section shall train project participants to earn a recognized postsecondary credential (including an industry-recognized credential, and a certificate awarded by a local workforce development board established under section 107 of the Workforce Innovation and Opportunity Act) that is awarded in recognition of attainment of measurable technical or occupational skills necessary to gain employment or advance within an occupation, and shall provide each project participant with a number of hours of the training equal to— (A) not less than the number of hours of training required for certification in that level of skill by the State in which the project is conducted; or (B) if there is no such requirement, such number of hours of training as the Secretary finds is necessary to achieve that skill level. (4) Inclusion of TANF recipients In the case of a project for which a grant is made under this section that is conducted in a State that has a program funded under part A of title IV, at least 10 percent of the eligible individuals to whom support is provided under the project shall meet the income eligibility requirements under that State program, without regard to whether the individuals receive benefits or services directly under that State program. (5) Income limitation An entity to which a grant is made under this section shall not use the grant to provide support to a person who is not an eligible individual. (6) Prohibition An entity to which a grant is made under this section shall not use the grant for purposes of entertainment, except that case management and career coaching services may include celebrations of specific career-based milestones such as completing a semester, graduation, or job placement. (e) Technical assistance (1) In general The Secretary shall provide technical assistance— (A) to assist eligible entities in applying for grants under this section; (B) that is tailored to meet the needs of grantees at each stage of the administration of projects for which grants are made under this section; (C) that is tailored to meet the specific needs of Indian tribes, tribal organizations, and tribal colleges and universities; (D) that is tailored to meet the specific needs of the territories; (E) that is tailored to meet the specific needs of eligible entities in carrying out demonstration projects for which a grant is made under this section; and (F) to facilitate the exchange of information among eligible entities regarding best practices and promising practices used in the projects. (2) Peer technical assistance conferences The Secretary shall hold peer technical assistance conferences for entities to which a grant is made under this section or was made under the immediate predecessor of this section. (f) Evaluation of demonstration projects (1) In general The Secretary shall, by grant, contract, or interagency agreement, conduct rigorous and well-designed evaluations of the demonstration projects for which a grant is made under this section. (2) Requirement applicable to individuals with arrest or conviction records demonstration In the case of a project of the type described in subsection (c)(2)(B)(i)(I), the evaluation shall include identification of successful activities for creating opportunities for developing and sustaining, particularly with respect to low-income individuals with arrest or conviction records, a health professions workforce that has accessible entry points, that meets high standards for education, training, certification, and professional development, and that provides increased wages and affordable benefits, including health care coverage, that are responsive to the needs of the workforce. (3) Requirement applicable to maternal mortality career pathway demonstration In the case of a project of the type described in subsection (c)(2)(B)(i)(II), the evaluation shall include identification of successful activities for creating opportunities for developing and sustaining, particularly with respect to low-income individuals and other entry-level workers, a career pathway that has accessible entry points, that meets high standards for education, training, certification, and professional development, and that provides increased wages and affordable benefits, including health care coverage, that are responsive to the needs of the birth, pregnancy, and post-partum workforce. (4) Rule of interpretation Evaluations conducted pursuant to this subsection may include a randomized controlled trial, but this subsection shall not be interpreted to require an evaluation to include such a trial. (g) Reports (1) To the Secretary An eligible entity awarded a grant to conduct a project under this section shall submit interim reports to the Secretary on the activities carried out under the project, and, on the conclusion of the project, a final report on the activities. Each such report shall include data on participant outcomes related to graduation rate, graduation timeliness, credential attainment, employment in health professions, overall employment, earnings, participant demographics, and other data specified by the Secretary. (2) To the Congress During each Congress, the Secretary shall submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate a report— (A) on the demographics of the participants in the projects for which a grant is made under this section; (B) on the rate of which project participants completed all activities under the projects; (C) on the employment credentials acquired by project participants; (D) on the employment of project participants on completion of activities under the projects, and the earnings of project participants at entry into employment; (E) on best practices and promising practices used in the projects; (F) on the nature of any technical assistance provided to grantees under this section; (G) on, with respect to the period since the period covered in the most recent prior report submitted under this paragraph— (i) the number of applications submitted under this section, with a separate statement of the number of applications referred to in subsection (b)(5); (ii) the number of applications that were approved, with a separate statement of the number of such applications referred to in subsection (b)(5); and (iii) a description of how grants were made in any case described in the last sentence of subsection (c)(1)(A)(ii); and (H) that includes an assessment of the effectiveness of the projects with respect to addressing health professions workforce shortages or in-demand jobs. (h) Definitions In this section: (1) Allied health profession The term allied health profession has the meaning given in section 799B(5) of the Public Health Service Act. (2) Career pathway The term career pathway has the meaning given that term in section 3(7) of the Workforce Innovation and Opportunity Act. (3) Doula The term doula means an individual who— (A) has completed 60 hours of foundational training; (B) is certified by an organization that has been established for not less than 5 years and that requires the completion of continuing education to maintain the certification, to provide non-medical advice, information, emotional support, and physical comfort to an individual during the individual’s pregnancy, childbirth, and post-partum period; and (C) maintains the certification by completing the required continuing education. (4) Eligible entity The term eligible entity means any of the following entities that demonstrates in an application submitted under this section that the entity has the capacity to fully develop and administer the project described in the application: (A) A local workforce development board established under section 107 of the Workforce Innovation and Opportunity Act. (B) A State or territory, a political subdivision of a State or territory, or an agency of a State, territory, or such a political subdivision, including a State or local entity that administers a State program funded under part A of this title. (C) An Indian tribe, a tribal organization, or a tribal college or university. (D) An institution of higher education (as defined in the Higher Education Act of 1965). (E) A hospital (as defined in section 1861(e)). (F) A high-quality skilled nursing facility. (G) A Federally qualified health center (as defined in section 1861(aa)(4)). (H) A nonprofit organization described in section 501(c)(3) of the Internal Revenue Code of 1986, a labor organization, or an entity with shared labor-management oversight, that has a demonstrated history of providing health profession training to eligible individuals. (I) In the case of a demonstration project of the type provided for in subsection (c)(2)(B)(i)(II) of this section, an entity recognized by a State, Indian tribe, or tribal organization as qualified to train doulas or midwives, if midwives or doulas, as the case may be, are permitted to practice in the State involved. (J) An opioid treatment program (as defined in section 1861(jjj)(2)), and other high quality comprehensive addiction care providers. (5) Eligible individual The term eligible individual means an individual whose family income does not exceed 200 percent of the Federal poverty level. (6) Federal poverty level The term Federal poverty level means the poverty line (as defined in section 673(2) of the Omnibus Budget Reconciliation Act of 1981, including any revision required by such section applicable to a family of the size involved). (7) Indian tribe; tribal organization The terms Indian tribe and tribal organization have the meaning given the terms in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450b ). (8) Institution of higher education The term institution of higher education has the meaning given the term in section 101 or 102(a)(1)(B) of the Higher Education Act of 1965. (9) MIdwife The term midwife means a midwife who meets, at a minimum, the international definition of the midwife and global standards for midwifery education as established by the International Confederation of Midwives. (10) Territory The term territory means the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. (11) Tribal college or university The term tribal college or university has the meaning given the term in section 316(b) of the Higher Education Act of 1965. (12) Tribal midwife The term tribal midwife means an individual who is recognized by an Indian tribe (as defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )) to practice midwifery for the tribe. (i) Funding (1) In general Out of any funds in the Treasury of the United States not otherwise appropriated, there are appropriated to the Secretary to carry out this section $425,000,000 for each of fiscal years 2024 through 2028. (2) Allocation of funds Of the amount appropriated for a fiscal year under paragraph (1) of this subsection— (A) 75 percent shall be available for grants under subsection (c)(1)(A); (B) 4 percent shall be reserved for grants under subsection (c)(1)(B); (C) 5 percent shall be reserved for grants under subsection (c)(1)(C); (D) 6 percent shall be available for demonstration project grants under subsection (c)(2); (E) 6 percent, plus all amounts referred to in subparagraphs (A) through (D) of this paragraph that remain unused after all grant awards are made for the fiscal year, shall be available for the provision of technical assistance and associated staffing; and (F) 4 percent shall be available for studying the effects of the demonstration and non-demonstration projects for which a grant is made under this section, and for associated staffing, for the purpose of supporting the rigorous evaluation of the demonstration projects, and supporting the continued study of the short-, medium-, and long-term effects of all such projects, including the effectiveness of specific elements of the non-demonstration projects. (j) Nonapplicability of preceding sections of this subtitle (1) In general Except as provided in paragraph (2), the preceding sections of this subtitle shall not apply to a grant awarded under this section. (2) Exception for certain limitations on use of grants Section 2005(a) (other than paragraphs (2), (3), (5), (6), and (8)) shall apply to a grant awarded under this section to the same extent and in the same manner as such section applies to payments to States under this subtitle. (k) Income disregard Amounts paid to an eligible individual as a cash stipend or as emergency assistance under a project for which a grant is made under this section shall not be considered income for any purpose under the Internal Revenue Code of 1986, and an entity making such a payment shall not be required to submit an information return under subtitle F of such Code with respect to the payment. .