[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4024 Introduced in House (IH)]

103d CONGRESS
  2d Session
                                H. R. 4024

To establish a national program of trained community health advisors to 
   assist the States in attaining the Healthy People 2000 Objectives.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 11, 1994

  Mr. Sanders (for himself, Mr. Dellums, Ms. Eddie Bernice Johnson of 
   Texas, Ms. Pelosi, Mr. Peterson of Minnesota, Ms. Velazquez, Mr. 
Beilenson, Mr. Owens, Mr. Hochbrueckner, Mr. Scott, Mr. Pastor, and Mr. 
   McHale) introduced the following bill; which was referred to the 
                    Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
To establish a national program of trained community health advisors to 
   assist the States in attaining the Healthy People 2000 Objectives.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``National Community Health Advisor 
Act''.

SEC. 2. FINDINGS.

    The Congress finds the following:
            (1) Poverty, geographic isolation, cultural differences, 
        lack of transportation, low literacy, lack of access to 
        services and further difficulties resulting from a lack of 
        continuity of care, are barriers for millions of low-income and 
        underserved Americans in the current health care delivery 
        system.
            (2) The Public Health Service has determined that many 
        health problems are rooted in poverty and hit hardest at those 
        least able to protect themselves.
            (3) The Public Health Service has established goals and 
        objectives regarding improvements in the health of the public 
        by the year 2000. An evaluation by the Service, entitled 
        ``Health United States 1992 and Healthy People 2000 Review'', 
        illustrates the acute access problem faced by rural areas and 
        the inner cities. The evaluation cites the fact that suburbs 
        have the lowest death rates, while death rates in rural 
        counties are 12 percent higher and in large core metropolitan 
        counties, 19 percent higher.
            (4) Discussions of health care reform focus almost 
        exclusively on questions of how to extend health insurance to 
        the Nation's 35-40 million uninsured and make services 
        available while simultaneously bringing medical cost under 
        control; however, it is imperative to correct the fundamental 
        and deep-rooted obstacles that low-income urban and rural 
        Americans confront when trying to access medical care and 
        preventive health services. For example, in 1991, 19 million 
        American women qualified for mammography screening benefits 
        through Medicare; however, only 670,000 (or less than 3 
        percent) took advantage of this benefit.
            (5) People who are local, indigenous members and residents 
        of underserved communities are uniquely knowledgeable about 
        their populations' needs; where such individuals are already 
        serving as community health advisors, they communicate to 
        health and social service providers the needs of community 
        members, provide quality health promotion and disease 
        prevention information to the community and serve as the 
        crucial link between their communities and providers to 
        increase utilization of available preventive health services 
        and to reach out to communities to increase the effectiveness 
        of the health care delivery system, reduce preventable 
        morbidity and mortality, and improve the quality of life.

SEC. 3. FORMULA GRANTS REGARDING COMMUNITY HEALTH ADVISOR PROGRAMS.

    (a) In General.--In the case of each State (or entity designated by 
a State under subsection (b)) that submits to the Secretary an 
application in accordance with section 6 for a fiscal year, the 
Secretary of Health and Human Services, acting through the Director of 
the Centers for Disease Control and Prevention, shall make an award of 
financial assistance to the State or entity for the development and 
operation of community health advisor programs under section 4(b). The 
award shall consist of the allotment determined under section 7 with 
respect to the State, subject to section 12(b).
    (b) Designated Entities.--With respect to the State involved, an 
entity other than the State may receive an award under paragraph (1) 
only if the entity--
            (1) is a public or nonprofit private academic organization 
        (or other public or nonprofit private entity); and
            (2) has been designated by the State to carry out the 
        purpose described in such paragraph in the State and to receive 
        amounts under such paragraph in lieu of the State.
    (c) Role of State Agency for Public Health.--A funding agreement 
for an award under subsection (a) is that--
            (1) if the applicant is a State, the award will be 
        administered by the State agency with the principal 
        responsibility for carrying out public health programs; and
            (2) if the applicant is an entity designated under 
        subsection (b), the award will be administered in consultation 
        with such State agency.
    (d) Statewide Responsibilities; Limitation on Expenditures.--
            (1) Statewide responsibilities.--A funding agreement for an 
        award under subsection (a) is that the applicant involved 
        will--
                    (A) operate a clearinghouse to maintain and 
                disseminate information on community health advisor 
                programs (and similar programs) in the State, including 
                information on developing and operating such programs, 
                on training individuals to participate in the programs, 
                and on evaluation of the programs;
                    (B) provide to community health advisor programs in 
                the State technical assistance in training community 
                health advisors under section 5(g)(1); and
                    (C) coordinate the activities carried out in the 
                State under the award, including coordination between 
                the various community health advisor programs and 
                coordination between such programs and related 
                activities of the State and of other public or private 
                entities.
            (2) Limitation.--A funding agreement for an award under 
        subsection (a) is that the applicant involved will not expend 
        more than 15 percent of the award in the aggregate for carrying 
        out paragraph (1) and for the expenses of administering the 
        award with respect to the State involved, including the process 
        of receiving payments from the Secretary under the award, 
        allocating the payments among the entities that are to develop 
        and operate the community health advisor programs involved, and 
        monitoring compliance with the funding agreements made under 
        this Act by the applicant.

SEC. 4. REQUIREMENTS REGARDING COMMUNITY HEALTH ADVISOR PROGRAMS.

    (a) Purpose of Award; Healthy People 2000 Objectives.--
            (1) In general.--Subject to paragraph (2), a funding 
        agreement for an award under section 3 for an applicant is that 
        the purpose of the award is, through community health advisor 
        programs under subsection (b), to assist the State involved in 
        attaining the Healthy People 2000 Objectives (as defined in 
        subsection (d).
            (2) Authority regarding selection of priority objectives.--
        With respect to compliance with the agreement made under 
        paragraph (1), an applicant receiving an award under section 3 
        may, from among the various Healthy People 2000 Objectives, 
        select one or more Objectives to be given priority in the 
        operation of a community health advisor program of the 
        applicant, subject to the applicant selecting such priorities 
        in consultation with the entity that is to carry out the 
        program.
    (b) Requirements for Programs.--
            (1) In general.--A funding agreement for an award under 
        section 3 for an applicant is that, in expending the award, the 
        purpose described in subsection (a)(1) will be carried out in 
        accordance with the following:
                    (A) For each community for which the purpose is to 
                be carried out, the applicant will establish a program 
                in accordance with this subsection.
                    (B) The program will be carried out in a community 
                only if the applicant has, under section 5(a), 
                identified the community as having a significant need 
                for the program.
                    (C) The program will be operated by a public or 
                nonprofit private entity with experience in providing 
                health or health-related social services to individuals 
                who are underserved with respect to such services.
                    (D) The services of the program, as specified in 
                paragraph (2), will be provided principally by 
                community health advisors (as defined in subsection 
                (d)).
            (2) Authorized program services.--For purposes of paragraph 
        (1)(D), the services specified in this paragraph for a program 
        are as follows:
                    (A) The program will collaborate with health care 
                providers and related entities in order to facilitate 
                the provision of health services and health-related 
                social services (including collaborating with local 
                health departments, community health centers, migrant 
                health centers, rural health clinics, hospitals, 
                physicians and nurses, providers of health education, 
                and providers of social services).
                    (B) The program will provide public education on 
                health promotion and disease prevention and facilitate 
                the use of available health services and health-related 
                social services.
                    (C) The program will provide health-related 
                counseling.
                    (D) The program will provide referrals for 
                available health services and health-related social 
                services.
                    (E) For the purpose of increasing the capacity of 
                individuals to utilize health services and health-
                related social services under Federal, State, and local 
                programs, the following conditions will be met:
                            (i) The program will assist individuals in 
                        establishing eligibility under the programs and 
                        in receiving the services or other benefits of 
                        the programs.
                            (ii) The program will provide such other 
                        services as the Secretary determines to be 
                        appropriate, which services may include (but 
                        are not limited to) transportation and 
                        translation services.
                    (F) The program will provide outreach services to 
                inform the community of the availability of the 
                services of the program.
    (c) Priority for Medically Underserved Communities.--A funding 
agreement for an award under section 3 is that the applicant involved 
will give priority to developing and operating community health advisor 
programs for medically underserved communities.
    (d) Certain Definitions.--
            (1) Community health advisor.--For purposes of this Act, 
        the term ``community health advisor'' means an individual--
                    (A) who has demonstrated the capacity to carry out 
                one or more of the authorized program services;
                    (B) who, for not less than 1 year, has been a 
                resident of the community in which the community health 
                advisor program involved is to be operated; and
                    (C) is a member of a socioeconomic group to be 
                served by the program.
            (2) Healthy people 2000 objectives.--For purposes of this 
        Act, the term ``Healthy People 2000 Objectives'' means the 
        objectives established by the Secretary toward increasing the 
        span of healthy life, reducing health disparities among various 
        populations, and providing access to preventive services, which 
        objectives apply to the health status of the population of the 
        United States for the year 2000.
            (3) Medically underserved community.--For purposes of this 
        Act, the term ``medically underserved community'' means--
                    (A) a community that has a substantial number of 
                individuals who are members of a medically underserved 
                population, as defined in section 330 of the Public 
                Health Service Act; or
                    (B) a community a significant portion of which is a 
                health professional shortage area designated under 
                section 332 of such Act.

SEC. 5. ADDITIONAL AGREEMENTS.

    (a) Identification of Community Needs.--A funding agreement for an 
award under section 3 that the applicant involved will--
            (1) identify the needs of the community involved for the 
        authorized program services;
            (2) in identifying such needs, consult with members of the 
        community, with individuals and programs that provide health 
        services in the community, and with individuals and programs 
        that provide health-related social services in the community; 
        and
            (3) consider such needs in carrying out a community health 
        advisor program for the community.
    (b) Matching Funds.--
            (1) In general.--With respect to the cost of carrying out a 
        community health advisor program, a funding agreement for an 
        award under section 3 is that the applicant involved will make 
        available (directly or through donations from public or private 
        entities) non-Federal contributions toward such cost in an 
        amount that is not less than 25 percent of such cost.
            (2) Determination of amount contributed.--
                    (A) Non-Federal contributions required in paragraph 
                (1) may be in cash or in kind, fairly evaluated, 
                including plant, equipment, or services. Amounts 
                provided by the Federal Government, or services 
                assisted or subsidized to any significant extent by the 
                Federal Government, may not be included in determining 
                the amount of such non-Federal contributions.
                    (B) With respect to the State in which the 
                community health advisor program involved is to be 
                carried out, amounts provided by the State in 
                compliance with subsection (c) shall be included in 
                determining the amount of non-Federal contributions 
                under paragraph (1).
    (c) Maintenance of Effort.--With respect to the purposes for which 
an award under section 3 is authorized in this Act to be expended, the 
Secretary may make such an award only if the State involved agrees to 
maintain expenditures of non-Federal amounts for such purposes at a 
level that is not less than the level of such expenditures maintained 
by the State for the fiscal year preceding the first fiscal year for 
which such an award is made with respect to the State.
    (d) Cultural Context of Services.--A funding agreement for an award 
under section 3 for an applicant is that the services of the community 
health advisor program involved will be provided in the language and 
cultural context most appropriate for the individuals served by the 
program.
    (e) Number of Programs Per Award; Programs for Urban and Rural 
Areas.--A funding agreement for an award under section 3 for an 
applicant is that the number of community health advisor programs 
operated in the State with the award will be determined by the 
Secretary, except that (subject to section 4(b)(1)(B)) such a program 
will be carried out in not less than one urban area of the State, and 
in not less than one rural area of the State.
    (f) Ongoing Supervision of Advisors.--A funding agreement for an 
award under section 3 is that the applicant involved will ensure that 
each community health advisor program operated with the award provides 
for the ongoing supervision of the community health advisors of the 
program.
    (g) Certain Expenditures.--
            (1) Training; continuing education.--Funding agreements for 
        an award under section 3 include the following:
                    (A) The applicant involved will ensure that, for 
                each community health advisor program operated with the 
                award, a program is carried out to train community 
                health advisors to provide the authorized program 
                services, including practical experiences in providing 
                services for health promotion and disease prevention.
                    (B) The program of training will provide for the 
                continuing education of the community health advisors.
                    (C) Not more than 15 percent of the award will be 
                expended for the program of training.
            (2) Compensation.--With respect to compliance with the 
        agreements made under this Act, the purposes for which an award 
        under section 3 may be expended include providing compensation 
        for the services of community health advisors.
    (h) Reports to Secretary; Assessment of Effectiveness.--Funding 
agreements for an award under section 3 for an applicant include the 
following:
            (1) The applicant will ensure that, for each fiscal year 
        for which a community health advisor program receives amounts 
        from the award, the program will prepare a report describing 
        the activities of the program for such year, including--
                    (A) a specification of the number of individuals 
                served by the program;
                    (B) a specification of the entities with which the 
                program has collaborated in carrying out the purpose 
                described in section 4(a)(1); and
                    (C) an assessment of the extent of the 
                effectiveness of the program in carrying out such 
                purpose.
            (2) Such reports will include such additional information 
        regarding the applicant and the programs as the Secretary may 
        require.
            (3) The applicant will prepare the reports as a single 
        document and will submit the document to the Secretary not 
        later than February 1 of the fiscal year following the fiscal 
        year for which the reports were prepared.

SEC. 6. APPLICATION FOR ASSISTANCE; STATE PLAN.

    The Secretary may make an award under section 3 only if--
            (1) an application for the award is submitted to the 
        Secretary;
            (2) the application is submitted not later than the date 
        specified by the Secretary;
            (3) the application contains each funding agreement 
        described in this Act;
            (4) the application contains a State plan describing the 
        purposes for which the award is to be expended in the State, 
        including a description of the manner in which the applicant 
        will comply with each such funding agreement; and
            (5) the application is in such form, is made in such 
        manner, and contains such agreements, assurances, and 
        information as the Secretary determines to be necessary to 
        carry out this Act.

SEC. 7. DETERMINATION OF AMOUNT OF ALLOTMENT.

    (a) In General.--For purposes of section 3, the allotment under 
this section with respect to a State for a fiscal year is the greater 
of--
            (1) the sum of the respective amounts determined for the 
        State under subsection (b) and subsection (c); and
            (2) $500,000.
    (b) Amount Relating to Population.--For purposes of subsection (a), 
the amount determined under this subsection is the product of--
            (1) an amount equal to 50 percent of the amount 
        appropriated under section 12 for the fiscal year and available 
        for awards under section 3; and
            (2) the percentage constituted by the ratio of--
                    (A) the number of individuals residing in the State 
                involved; to
                    (B) the sum of the respective amounts determined 
                for each State under subparagraph (A).
    (c) Amount Relating to Poverty Level.--For purposes of subsection 
(a), the amount determined under this subsection is the product of--
            (1) the amount determined under subsection (b)(1); and
            (2) the percentage constituted by the ratio of--
                    (A) the number of individuals residing in the State 
                whose income is at or below an amount equal to 200 
                percent of the official poverty line; to
                    (B) the sum of the respective amounts determined 
                for each State under subparagraph (A).

SEC. 8. QUALITY ASSURANCE; COST-EFFECTIVENESS.

    The Secretary shall establish guidelines for assuring the quality 
of community health advisor programs (including quality in the training 
of community health advisors) and for assuring the cost-effectiveness 
of the programs. A funding agreement for an award under section 3 is 
that the applicant involved will carry out such programs in accordance 
with the guidelines.

SEC. 9. EVALUATIONS; TECHNICAL ASSISTANCE.

    (a) Evaluations.--The Secretary shall conduct evaluations of 
community health advisor programs, and may disseminate information 
developed as result of the evaluations. In conducting such evaluations, 
the Secretary shall determine whether the programs are in compliance 
with the guidelines established under section 8.
    (b) Technical Assistance.--The Secretary may provide technical 
assistance to recipients of awards under section 3 with respect to the 
planning, development, and operation of community health advisor 
programs.
    (c) Grants and Contracts.--The Secretary may carry out this section 
directly or through grants, cooperative agreements, or contracts.
    (d) Limitation on Expenditures.--Of the amounts appropriated under 
section 12 for a fiscal year, the Secretary may reserve not more than 
10 percent for carrying out this section.

SEC. 10. RULE OF CONSTRUCTION REGARDING PROGRAMS OF INDIAN HEALTH 
              SERVICE.

    This Act may not be construed as requiring the Secretary to modify 
or terminate the program carried out by the Director of the Indian 
Health Service and designated by such Director as the Community Health 
Representative Program. The Secretary shall ensure that support for 
such Program is not supplanted by awards under section 3. In 
communities in which both such Program and a community health advisor 
program are being carried out, the Secretary shall ensure that the 
community health advisor program works in cooperation with, and as a 
complement to, the Community Health Representative Program.

SEC. 11. DEFINITIONS.

    For purposes of this Act:
            (1) The term ``authorized program services'', with respect 
        to a community health advisor program, means the services 
        specified in section 4(b)(2).
            (2) The term ``community health advisor'' has the meaning 
        given such term in section 4(d).
            (3) The term ``community health advisor program'' means a 
        program carried out under section 4(b).
            (4) The term ``financial assistance'', with respect to an 
        award under section 3, means a grant, cooperative agreement, or 
        a contract.
            (5) The term ``funding agreement'' means an agreement 
        required as a condition of receiving an award under section 3.
            (6) The term ``Healthy People 2000 Objectives'' has the 
        meaning given such term in section 4(d).
            (7) The term ``medically underserved community'' has the 
        meaning given such term in section 4(d).
            (8) The term ``official poverty line'' means the official 
        poverty line established by the Director of the Office of 
        Management and Budget and revised by the Secretary in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981.
            (9) The term ``Secretary'' means the Secretary of Health 
        and Human Services.
            (10) The term ``State'' means each of the several States, 
        the District of Columbia, and each of the Commonwealth of 
        Puerto Rico, American Samoa, Guam, the Commonwealth of the 
        Northern Mariana Islands, the Virgin Islands, and the Trust 
        Territory of the Pacific Islands.
            (11) The term ``State involved'', with respect to an 
        applicant for an award under section 3, means the State in 
        which the applicant is to carry out a community health advisor 
        program.

SEC. 12. FUNDING.

    (a) Authorization of Appropriations.--For the purpose of carrying 
out this Act, there is authorized to be appropriated $100,000,000 for 
each of the fiscal years 1995 through 2000.
    (b) Effect of Insufficient Appropriations for Minimum Allotments.--
            (1) In general.--If the amounts made available under 
        subsection (a) for a fiscal year are insufficient for providing 
        each State (or entity designated by the State pursuant to 
        section 3, as the case may be) with an award under section 3 in 
        an amount equal to or greater than the amount specified in 
        section 7(a)(2), the Secretary shall, from such amounts as are 
        made available under subsection (a), make such awards on a 
        discretionary basis.
            (2) Rule of construction.--For purposes of paragraph (1), 
        awards under section 3 are made on a discretionary basis if the 
        Secretary determines which States (or entities designated by 
        States pursuant to such section, as the case may be) are to 
        receive such awards, subject to meeting the requirements of 
        this Act for such an award, and the Secretary determines the 
        amount of such awards.

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