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SECTION 1. SHORT TITLE.

This Act may be cited as the ''Humanitarian Exports Leading to
Peace Act of 2001''.

SEC. 2. FINDINGS.

The Congress finds the following:
(1) The Iraqi people suffered under a decade of war and
continue to suffer under a repressive regime and the most
comprehensive economic sanctions ever imposed on any country.
(2) The economic sanctions have caused extraordinary
hardship on the people of Iraq and failed to weaken the
leadership of Iraq, and have undermined the institutions of
civil society which are necessary for democratic political
life.
(3) The investigative panel established by the United
Nations Security Council and other independent bodies have
confirmed that the United Nations Oil-for-Food program has
failed to adequately meet the needs of the Iraqi people.
(4) According to the United States Department of
Agriculture, Iraq represents a potential market for nearly
$1,000,000,000 in agricultural products from the United States.
(5) The sanctions regime continues to harm the Iraqi
population for the crimes of its leaders and has not served
either the goal of the United States of punishing Iraq's
leaders or disarming weapons of mass destruction.
(6) Rigorous weapons inspections and adequate provision for
civilian needs in Iraq are not mutually exclusive.
(7) The devastating effect of the economic sanctions on
Iraq has been reported by numerous international and
independent bodies, including the following:
(A) The Center for Economic and Social Rights of
the United Nations documented dramatic increases in
malnutrition and disease, leading to the deaths of
hundreds of thousands of children under the age of 5
since 1991.
(B) UNICEF reported in 1995 that ''no significant
movement towards food security can be achieved so long
as the embargo remains in place''. Further, despite the
Oil-for-Food Program, UNICEF reported in July 1999
survey findings that ''Both the infant mortality rate
and the under-five mortality rate consistently show a
major increase in mortality over the 10 years preceding
the survey. More specifically, the results show that
the infant mortality rate has increased from 47 deaths
per 1,000 live births for the period 1984-89, to 108
deaths per 1,000 live births for the period 1994-99.''.
(C) A report authorized by the United National
Security Council on March 30, 1999, found that ''the
gravity of the humanitarian situation of the Iraqi
people is indisputable and cannot be overstated.''.
Further, it emphasized that ''Even if not all suffering
in Iraq can be imputed to external factors, especially
sanctions, the Iraqi people would not be undergoing
such deprivations in the absence of the prolonged
measures imposed by the Security Council and the
effects of the war''.
(D) UNICEF and the World Food Program found in 1997
that ''One out of every 4 young Iraqi children is
malnourished. More than 750,000 children are suffering
from malnutrition''.

SEC. 3. LIMITATION ON PROHIBITIONS AND RESTRICTIONS ON TRADE WITH IRAQ
TO ALLOW FOR THE EXPORT OF FOOD, MEDICINES, AND CERTAIN
OTHER PRODUCTS.

The sanctions applied with respect to Iraq under the Iraq Sanctions
Act of 1990 (sections 586-586J of the Foreign Operations, Export
Financing, and Related Programs Appropriations Act, 1991 (Public Law
101-513)) or any other provision of law shall not apply with respect to
the export to Iraq of any food or other agricultural products
(including fertilizer), medicines, medical supplies, medical
instruments, or medical equipment, or with respect to travel incident
to the sale or delivery to Iraq of food or other agricultural products
(including fertilizer), medicines, medical supplies, medical
instruments, or medical equipment.

SEC. 4. ADMINISTRATION BY SECRETARY OF COMMERCE.

(a) Administration by Secretary of Commerce.--The Secretary of
Commerce shall exercise the authorities of the Export Administration
Act of 1979, as in effect pursuant to the International Emergency
Economic Powers Act, to carry out section 3, except that--
(1) the Secretary may not require a license for the export
of any of the items to which section 3 applies; but
(2) the Secretary shall require persons exporting such
items to notify the Secretary of such exports.
(b) Regulations.--The Secretary of Commerce shall issue such
regulations as are necessary to carry out section 3.

SEC. 5. CONFORMING AMENDMENT.

Section 906(a)(1) of the Trade Sanctions Reform and Export
Enhancement Act of 2000 (title IX of H.R. 5426 of the 106th Congress,
as enacted into law by section 1(a) of Public Law 106-387) is amended
by inserting ''(other than Iraq)'' after ''government of a country''.

SEC. 6. SENSE OF CONGRESS.

It is the sense of the Congress that the United States Government
should take all necessary steps to end the suffering of innocent
populations, primarily children and the elderly, by allowing the free
flow of humanitarian aid to Iraq without threat of prosecution. Such
steps should include, but not be limited to, using its position as a
permanent member of the United Nations Security Council--
(1) to lift the economic sanctions on Iraq so as to allow
exports and travel referred to in section 3; and
(2) to recommend a ban on transfers of weapons to Iraq by
countries that are members of the United Nations.

SEC. 7. REPORT TO CONGRESS.

Not later than 6 months after the date of the enactment of this
Act, the President shall transmit to the Congress a report that sets
forth--
(1) the extent (expressed in volume and dollar amounts) of
sales to Iraq of food and other agricultural products
(including fertilizer), medicines, medical supplies, medical
instruments, and medical equipment, since the enactment of this
Act;
(2) the impact the exports have had on food security in
Iraq;
(3) a description of the types and end users of the goods
so exported;
(4) whether there has been any indication that any
medicines, medical supplies, medical instruments, or medical
equipment exported to Iraq since the enactment of this Act--
(A) have been diverted by the Government of Iraq or
any other third party from the intended recipients; or
(B) have been used for any unintended
nonhumanitarian or dual-use purposes; and
(5) what steps the United States has taken through the
United Nations, with the cooperation of Security Council
members, to--
(A) lift nonmilitary sanctions on Iraq, including
actions described in section 6; or
(B) impose a strict regional arms control regime
pursuant to Article 14 of Security Council Resolution
687.
Humanitarian Exports Leading to Peace Act of 2001 - Declares that certain sanctions prohibiting trade with Iraq under the Iraq Sanctions Act of 1990 or any other provision of law shall not apply with respect to the export of any food or other agricultural products (including fertilizer), medicines, medical supplies, medical instruments, or medical equipment, or with respect to travel incident to the sale or delivery of such items.Directs the Secretary of Commerce to exercise the authorities of the Export Administration Act of 1979 (as in effect pursuant to the International Emergency Economic Powers Act) to carry out this Act; except that the Secretary may not require a license for the export of humanitarian assistance, but shall require persons to notify the Secretary when exporting such assistance.Amends the Trade Sanctions Reform and Export Enhancement Act of 2000 to repeal a specified section prohibiting the export to Iraq of agricultural commodities (including the financing of their sale), medicine, or medical devices, and travel (effectively allowing the export of such commodities and travel to such country).Expresses the sense of Congress that the U.S. Government should take all necessary steps to end the suffering of innocent populations, primarily children and the elderly, by allowing the free flow of humanitarian aid to Iraq without threat of prosecution. Urges the U.S. Government to use its position as a permanent member of the United Nations (UN) Security Council to lift the economic sanctions on Iraq so as to allow such exports and travel there, and to recommend a ban on transfers of weapons to such country by countries that are members of the UN.

SECTION 1. SHORT TITLE.

This Act may be cited as the ''Shareholder Empowerment Act of
2009''.

SEC. 2. MAJORITY VOTING FOR DIRECTORS.

The Securities Exchange Act of 1934 is amended by adding after
section 16 the following new section:

''SEC. 16A. ELECTION OF DIRECTORS.

''(a) Standards Relating to Election of Directors.--
''(1) Commission rules.--Not later than 270 days after the
date of enactment of this section, the Commission shall, by
rule, direct the national securities exchanges and national
securities associations to prohibit the listing of any security
of an issuer that is not in compliance with the requirements of
any portion of paragraph (2). Such rules shall provide for
appropriate procedures for an issuer to have an opportunity to
cure any defects that would be the basis for such a prohibition
before the imposition of such prohibition.
''(2) Standards for election of directors.--
''(A) Majority voting.--Each issuer shall, to the
extent permitted under State law, provide in its
governing documents that--
''(i) directors in uncontested elections
shall be elected by a majority of the votes
cast as to each nominee; and
''(ii) in contested elections where the
number of nominees exceeds the number of
directors to be elected, directors shall be
elected by the vote of a plurality of the
shares represented at any meeting and entitled
to vote on the election of directors.
''(B) Resignation policy.--Each issuer shall also,
to the extent permitted under State law, adopt
procedures under which any director who is not elected
to a new term shall offer to tender his or her
resignation to the board of directors. The board of
directors, with the advice of a committee of the board
if such a committee has been established for that
purpose, shall determine what action should be taken as
to that resignation and shall publicly disclose its
decision and the rationale for that decision within a
reasonable period after certification of the election
results.
''(b) Shareholder Access to the Proxy in Director Elections.--
''(1) Rule.--Not later than 270 days after the date of
enactment of this section, the Commission shall, by rule,
require that in proxy statements and proxies, authorizations or
consents prepared by an issuer pursuant to section 14, the
issuer shall identify and provide security holders with an
opportunity to vote on candidates for the board of directors
who have been nominated by holders in the aggregate at least 1
percent of the issuer's voting securities for at least 2 years
prior to a record date established by the issuer for a meeting
of security holders.
''(2) Application.--This rule shall specify the information
to be provided to an issuer by security holders who nominate
candidates for inclusion in an issuer's proxy materials under
this section and shall require the issuer to disclose
information about such candidates in the issuer's proxy
materials to the same extent that information must be disclosed
about candidates nominated by the issuer. This rule shall apply
only when eligible security holders have nominated fewer than a
majority of the number of directors then authorized to serve on
the board of directors, and the rule shall specify procedures
to be followed if different security holders nominate
candidates sufficient to constitute a majority of the board of
directors.
''(3) Effective date.--The rule shall apply to proxy voting
for meetings of security holders held on or after January 1,
2010, except to the extent that a meeting was originally
scheduled to be held in 2009, but was adjourned to 2010.
''(c) Broker Discretionary Voting in Uncontested Director
Elections.--Not later than 270 days after the date of enactment of this
section, the Commission shall by, rule, require that a broker shall not
be allowed to vote securities on an uncontested election to the board
of directors of an issuer to the extent that the beneficial owner of
those securities has not provided specific instructions to the broker.
The rule shall apply to proxy voting for meetings of security holders
held on or after January 1, 2010, except to the extent that a meeting
was originally scheduled to be held in 2009, but was adjourned to 2010.
''(d) Independent Chairman of the Board of Directors.--
''(1) Commission rules.--Not later than 270 days after the
date of enactment of this section, the Commission shall, by
rule, direct the national securities exchanges and national
securities associations to prohibit the listing of any security
of an issuer that is not in compliance with the requirements of
any portion of paragraph (2). Such rules shall provide for
appropriate procedures for an issuer to have an opportunity to
cure any defects that would be the basis for such a prohibition
before the imposition of such prohibition.
''(2) Independent chairman of the board of directors.--Each
issuer shall provide in its governing documents or a public
statement of corporate policy that, to the extent possible and
consistent with the issuer's status as a publicly traded
company, the chairman of the board of directors shall be an
independent director who has not previously served as an
executive officer of the issuer. Such rule shall be implemented
with due regard for contracts in existence on the date of
enactment of this section. For purposes of this subsection, an
'independent director' shall be one who during the preceding 5
years has not been--
''(A) employed by the issuer in an executive
capacity;
''(B) an employee, director or owner greater than
20 percent of the beneficial shares of a firm that is a
paid adviser or consultant to the issuer;
''(C) employed by a significant customer or
supplier of the issuer;
''(D) a party to a personal services contract with
the issuer, as well as with the issuer's Chair, chief
executive officer, or other senior executive officer;
''(E) an employee, officer or director of a
foundation, university or other non-profit organization
that receives the greater of $100,000 or 1 percent of
total annual donations from the issuer;
''(F) a relative of an executive of the issuer;
''(G) part of an interlocking directorate in which
the issuer's chief executive officer or another
executive serves on the board of another issuer
employing that director; and
''(H) engaged in any other relationship with the
issuer or senior executives that the Commission
determines would not render that director an
independent director.''.

SEC. 3. EXECUTIVE COMPENSATION REQUIREMENTS.

The Securities Exchange Act of 1934 is further amended by adding
after the section 16A, as added by section 2, the following new section

''SEC. 16B. EXECUTIVE COMPENSATION REQUIREMENTS.

''(a) Shareholder Approval of Executive Compensation.--
''(1) Annual shareholder vote on executive compensation.--
Any proxy or consent or authorization for an annual or other
meeting of an issuer shall permit a separate vote by
shareholders to approve the compensation of senior executive
officers, as disclosed pursuant to the compensation disclosure
rules of the Commission (which disclosure shall include the
compensation discussion and analysis, the compensation tables,
and any related material).
''(2) Non-binding nature of vote.--A shareholder vote
described in paragraph (1) shall not be binding on the board of
directors of an issuer and may not be construed as overruling a
decision by such board, nor to create or imply any additional
fiduciary duty by such board, nor shall such vote be construed
to restrict or limit the ability of security holders to make
proposals for inclusion in proxy materials related to executive
compensation.
''(3) Deadline for rules.--Not later than 1 year after the
date of enactment of this section, the Commission shall issue
any final rules and regulations required by this section.
''(4) Exception.--This provision shall not apply to any
issuer who is subject to a similar recoupment requirement under
another provision of Federal law.
''(b) Independent Compensation Advisers.--
''(1) Requirement.--Not later than 1 year after the date of
enactment of this section, the Commission shall, by rule,
require that if an issuer's board of directors or a committee
thereof retains an individual adviser or advisory firm in
conjunction with negotiating employment contracts or
compensation agreements with the issuer's executives, the
individual adviser and his or her firm shall be independent of
the issuer, its executives and directors, and shall report
solely to the board of directors or the committee thereof
responsible for executive compensation. The rule shall further
require that issuers shall not agree to indemnify or limit the
liability of compensation advisers or advisory firms.
''(2) Determination.--In determining the extent to which an
adviser or advisory firm is independent of an issuer within the
meaning of this section, the Commission shall consider such
matters as--
''(A) the extent (as measured by annual fees and
other relevant metrics) to which an individual adviser
or advisory firm provides services in conjunction with
negotiating employment contracts or compensation
agreements with the issuer's executives, as compared to
other services that the adviser or advisory firm
provides to the issuer or executives;
''(B) whether individual advisers are permitted to
hold equity and do hold equity in the issuer; and
''(C) whether an advisory firm's incentive
compensation plan links the compensation of individual
advisers to the advisory firm's provision of other
services to the issuer.
''(c) Clawbacks of Unearned Performance-Based Pay.--
''(1) Commission rules.--Not later than 270 days after the
date of enactment of this section, the Commission shall, by
rule, direct the national securities exchanges and national
securities associations to prohibit the listing of any security
of an issuer that is not in compliance with the requirements of
any portion of paragraph (2). Such rules shall provide for
appropriate procedures for an issuer to have an opportunity to
cure any defects that would be the basis for such a prohibition
before the imposition of such prohibition.
''(2) Recoupment of unearned compensation.--An issuer's
board of directors or a committee thereof shall develop and
disclose a policy for reviewing unearned bonus payments,
incentive payments, or equity payments that were awarded to
executive officers owing to fraud, financial results that
require restatement, or some other cause. The policy should
require recovery or cancellation of any unearned payments to
the extent that it is feasible and practical to do so.
''(3) Exception.--This provision shall not apply to any
issuer who is subject to a similar recoupment requirement under
another provision of Federal law.
''(d) Severance Agreements Tied to Performance.--
''(1) Commission rules.--Not later than 270 days after the
date of enactment of this section, the Commission shall, by
rule, direct the national securities exchanges and national
securities associations to prohibit the listing of any security
of an issuer that is not in compliance with the requirements of
any portion of paragraph (2). Such rules shall provide for
appropriate procedures for an issuer to have an opportunity to
cure any defects that would be the basis for such a prohibition
before the imposition of such prohibition.
''(2) Severance agreements tied to performance.--An
issuer's board of directors or a committee thereof shall not
enter into agreements providing for severance payments to a
senior executive officer who is terminated because of poor
performance as an executive, as determined by the board of
directors. To the extent that an issuer is able to terminate a
senior executive officer for cause, poor performance by the
executive, as determined by the board of directors, shall be
considered as one such cause. The rule shall be implemented
with due regard for contracts in existence on the date of
enactment of this section.
''(e) Improved Disclosure of Compensation Targets.--Not later than
1 year after the date of enactment of this section, the Commission
shall, by rule, require additional disclosure of specific performance
targets that are used by issuers to determine a senior executive
officer's eligibility for bonuses, equity and incentive compensation.
The Commission shall consider methods to improve disclosure in
situations when it is claimed that disclosure would result in
competitive harm to the issuer, including, requirements that the issuer
describe its past experience with similar target levels, disclose any
inconsistencies between compensation targets and targets set in other
contexts, submit a request for confidential treatment of the
performance targets under Commission rules, or disclose the data after
disclosure would no longer be considered competitively harmful.''.
Shareholder Empowerment Act of 2009 - Amends the Securities Exchange Act of 1934 to direct the Securities and Exchange Commission (SEC) to prohibit national securities exchanges and associations from listing the securities of any issuer unless, to the extent permitted by state law, such issuer requires: (1) the election of directors who receive the majority of votes in uncontested elections or a plurality of votes in contested elections; and (2) directors who are not reelected to offer to tender their resignations.

Directs the SEC to: (1) require issuers to identify and provide security holders with an opportunity to vote on director candidates who have been nominated by holders of at least 1% of the issuer's voting securities for at least two years, provided security holders have nominated fewer than a majority of the directors then authorized to serve; (2) prohibit brokers from voting securities on an uncontested election to the board of directors without having received specific instructions from the securities' beneficial owners; and (3) requires listed issuers, to the extent possible, to have an independent chairman of their board of directors who has not served as an executive of the issuer.

Requires any proxy or consent or authorization for an annual or other meeting of a securities issuer to permit a separate shareholder vote on executive compensation, though such vote shall not be binding on its board of directors.

Directs the SEC to direct the national securities exchanges and national securities associations to prohibit: (1) issuers from retaining advisors in negotiating executive employment or compensation agreements that are not independent or are protected from liability by such issuers; (2) the listing of issuers that do not have a (clawback) policy of recovering executive payments that were unearned due to fraud, faulty financial statements, or some other cause; and (3) the listing of issuers that provide severance payments to senior executives who are terminated for poor performance.

Directs the SEC to require additional disclosure of specific performance targets issuers use in determining a senior executive's eligibility for bonuses, equity, and incentive compensation.

SECTION 1. SHORT TITLE.

This Act may be cited as the ''Ambulatory Surgical Center Medicare
Payment Modernization Act of 2005''.

SEC. 2. MEDICARE PAYMENT FOR AMBULATORY SURGICAL CENTER SERVICES.

(a) In General.--Section 1833(i) of the Social Security Act (42
U.S.C. 1395l(i)) is amended to read as follows:
''(i)(1) Payment shall be made under this part in the amount
specified under paragraph (2) for facility services furnished to an
individual in an ambulatory surgical center in connection with any
outpatient surgical procedure covered under this part as a hospital
outpatient department service, except for those procedures that the
Secretary designates, in consultation with appropriate trade and
professional organizations (including those having direct experience
with ambulatory surgical centers) as posing a significant safety risk
or requiring an overnight stay when performed in ambulatory surgical
centers. Not less frequently than once every two years the Secretary
shall review and, may, after public comment, make appropriate
adjustments to this list of procedures excluded from coverage when
performed in ambulatory surgical centers as the Secretary deems
necessary.
''(2)(A) Subject to subparagraphs (B) and (C), the amount of
payment to be made under this subsection for facility services
furnished to an individual in an ambulatory surgical center in
accordance with paragraph (1) shall be equal to 75 percent of the fee
schedule amount determined under paragraph (3)(A) of subsection (t) for
payment of the same service furnished in hospital outpatient
departments, as adjusted under paragraphs (4)(A), (6), and (15) of such
subsection, less a 20 percent beneficiary copayment.
''(B) For covered ambulatory surgical center services furnished on
or after January 1, 2008, and before January 1, 2012, for which the
ambulatory surgical center payment amount payable under this subsection
in 2007 (in this subsection referred to as the '2007 ASC payment
amount') is less than 75 percent of the hospital OPD fee schedule
amount under subsection (t) in 2007 for the same services, the amount
of payment under this subsection shall be calculated as follows:
''(i) For services furnished during 2008, the amount shall
be equal to the sum of--
''(I) 80 percent of the 2007 ASC payment amount, as
increased by the percentage increase in the consumer
price index for all urban consumers (United States city
average) as estimated by the Secretary for the 12-month
period ending with December 31, 2006; and
''(II) 20 percent of the payment amount under
paragraph (2)(A) for 2008.
''(ii) For services furnished during 2009, the amount shall
be equal to the sum of--
''(I) 60 percent of the 2007 ASC payment amount as
increased under clause (i)(I) and as further increased
by the percentage increase in the consumer price index
for all urban consumers (United States city average) as
estimated by the Secretary for the 12-month period
ending with December 31, 2007; and
''(II) 40 percent of the payment amount under
paragraph (2)(A) for 2009.
''(iii) For services furnished during 2010, the amount
shall be equal to the sum of--
''(I) 40 percent of the 2007 ASC payment amount as
increased under clauses (i)(I) and (ii)(I) and as
further increased by the percentage increase in the
consumer price index for all urban consumers (United
States city average) as estimated by the Secretary for
the 12-month period ending with December 31, 2008; and
''(II) 60 percent of the payment amount under
paragraph (2)(A) for 2010.
''(iv) For services furnished during 2011, the amount shall
be equal to the sum of--
''(I) 20 percent of the 2007 ASC payment amount as
increased under clauses (i)(I), (ii)(I), and (iii)(I)
and as further increased by the percentage increase in
the consumer price index for all urban consumers
(United States city average) as estimated by the
Secretary for the 12-month period ending with December
31, 2009; and
''(II) 80 percent of the payment amount under
paragraph (2)(A) for 2011.
''(C) For covered ambulatory surgical center services for which the
2007 ASC payment amount is--
''(i) greater than 75 percent, but less than 100 percent,
of the hospital OPD fee schedule amount under subsection (t) in
2007 for the same services, the amount of payment under this
subsection shall be the greater of the 2007 ASC payment amount
or--
''(I) for services furnished in 2008, the payment
amount under subparagraph (B)(i);
''(II) for services furnished in 2009, the payment
amount under subparagraph (B)(ii);
''(III) for services furnished in 2010, the payment
amount under subparagraph (B)(iii);
''(IV) for services furnished in 2011, the payment
amount under subparagraph (B)(iv); or
''(V) in 2012 and subsequent years, the payment
amount under subparagraph (A),
but in no case in excess of the then applicable hospital OPD
fee schedule amount; or
''(ii) greater than the hospital OPD fee schedule amount
under subsection (t) in 2007 for the same services, the amount
of payment under this subsection--
''(I) for services furnished during 2008, is equal
to the midpoint between the 2007 ASC payment amount and
100 percent of such 2007 hospital OPD fee schedule
amount; or
''(II) for services furnished in a subsequent year
is equal to the greater of the 2007 hospital OPD fee
schedule amount or the payment amount specified under
subclause (I) through (V) of clause (i) for the year
involved, but but in no case in excess of the then
applicable hospital OPD fee schedule amount.''.
(b) Conforming Amendments.--
(1) Section 1832(a)(2)(F)(i) of such Act (42 U.S.C.
1395k(a)(2)(F)(i)) is amended--
(A) by striking ''section 1833(i)(1)(A)'' and
inserting ''section 1833(i)(1)'';
(B) by striking ''the standard overhead amount as
determined under section 1833(i)(2)(A)'' and inserting
''the amount determined under section 1833(i)(2)''; and
(C) by striking all that follows ''as full payment
for such services'' and inserting '', or''.
(2) Section 1833(a)(1)(G) of such Act (42 U.S.C.
1395l(a)(1)(G)) is amended--
(A) by striking ''subsection (i)(1)(A)'' and
inserting ''subsection (i)(1)'';
(B) by striking ''for services furnished
beginning'' and all that follows through ''subsection
(i)(2)(D)''; and
(C) by striking ''such revised payment system'' and
inserting ''under subsection (i)(2)''.
(3) Section 1833(a)(4) of such Act (42 U.S.C. 1395l(a)(4))
is amended--
(A) by striking ''section 1833(i)(1)(A)'' and
inserting ''subsection (i)(1)''; and
(B) by striking ''paragraph (2) or (3) of
subsection (i)'' and inserting ''subsection (i)(1)''.
(c) Effective Date.--The amendments made by this section shall
apply to ambulatory surgical center services furnished on or after
January 1, 2008.
Ambulatory Surgical Center Medicare Payment Modernization Act of 2005 - Amends title XVIII (Medicare) of the Social Security Act to revise the requirements and the formula for payments for services furnished to individuals in ambulatory surgical centers.