[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[S. 3413 Introduced in Senate (IS)]







110th CONGRESS
  2d Session
                                S. 3413

To achieve access to comprehensive primary health care services for all 
Americans and to improve primary care delivery through an expansion of 
the community health center and National Health Service Corps programs.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             July 31, 2008

  Mr. Sanders (for himself, Mr. Obama, Mrs. Clinton, Mr. Kennedy, Mr. 
Brown, Ms. Mikulski, Mr. Casey, Mrs. Boxer, Mr. Durbin, and Mr. Inouye) 
introduced the following bill; which was read twice and referred to the 
          Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
To achieve access to comprehensive primary health care services for all 
Americans and to improve primary care delivery through an expansion of 
the community health center and National Health Service Corps programs.

    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 ``Access for All America Act''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Providing health coverage for all Americans will be 
        incomplete if access to services is not improved.
            (2) Currently, almost 60,000,000 Americans, both insured 
        and uninsured, have inadequate access to primary care due to a 
        shortage of such physicians and other like providers in their 
        community.
            (3) Several demonstrations are underway at the Federal and 
        State levels to link patients to a primary care ``medical 
        home'' as a means of assuring access, controlling costs, and 
        improving quality.
            (4) Yet, there already exists a proven medical home model 
        that accomplishes these goals and has done so over the past 40 
        years while serving over 17,000,000 Americans.
            (5) Community health centers, also known as Federally 
        Qualified Health Centers (FQHCs), have been found to more than 
        pay for themselves by providing coordinated, comprehensive 
        medical, dental, behavioral health, and prescription drug 
        services that reduces unnecessary emergency room visits, 
        ambulatory-sensitive hospitalizations, and avoidable specialty 
        care.
            (6) The result is that the American Academy of Family 
        Practitioners' Robert Graham Center found that medical expenses 
        for health center patients are 41 percent lower compared to 
        patients seen elsewhere, an average savings of $1,810 per 
        person per year.
            (7) The Lewin Group found that providing access to a 
        medical home for every American would produce health care 
        savings of $60,700,000,000 per year, more than 7 times the 
        subsidy needed to sustain the 1,100 current health centers and 
        to create 3,700 new health centers to accomplish full access.
            (8) Hand-in-hand with the expansion of the community health 
        center program, a renewed investment in the National Health 
        Service Corps is essential to reverse the decline in the supply 
        of primary care physicians and dentists.
            (9) Both the expansion of the community health center 
        program and the investment in the National Health Service Corps 
        can be accomplished for less than 1 percent of total health 
        care spending today.
            (10) Finally, to encourage the broader adoption of the 
        cost-effective community health center model of care beyond 
        underserved areas and populations and to encourage the pursuit 
        and practice of primary care as a career, all willing primary 
        care practitioners should be provided with incentives and 
        support to organize as community health center practices.

SEC. 3. FEDERALLY QUALIFIED HEALTH CENTER (FQHC) OPERATING SUPPORT.

    (a) In General.--The Secretary of health and Human Services 
(referred to in this Act as the ``Secretary)'', acting through the 
Administrator of the Health Resources and Services Administration, 
shall award grants to eligible entities to carry out activities under 
operating plans submitted under section 5.
    (b) Eligibility.--To be eligible to receive a grant under 
subsection (a), an entity shall--
            (1) be a public or nonprofit private entity that in fiscal 
        year 2009, was certified by the Secretary as a federally 
        qualified health center (including a recipient of a grant under 
        section 330 of the Public Health Service Act (42 U.S.C. 254b), 
        or an Urban Indian Clinic or Indian Tribal Health Clinic);
            (2) comply with the general requirements of section 4; and
            (3) submit to the Secretary an application at such time, in 
        such manner, and containing such information as the Secretary 
        may require, including an operating plan in accordance with 
        section 5.
    (c) Conversion of Existing Primary Care Practices to FQHC Status.--
            (1) In general.--A medical practice that is organized 
        solely for the purpose of providing primary care (family 
        medicine, general internal medicine, pediatrics, or general 
        obstetric and gynecological services that are furnished by 
        physicians and, where appropriate, physician assistants, nurse 
        practitioners, and nurse midwives) shall be eligible for 
        designation as a federally qualified health center under 
        section 1861(aa)(4)(B) of the Social Security Act (42 U.S.C. 
        1395x(aa)(4)(B)) if such practice--
                    (A) is organized as a nonprofit private entity; and
                    (B) meets the requirements of section 4.
            (2) Location.--An entity described in paragraph (1) shall 
        not be required to be located in a medically underserved area.
            (3) Limitation.--An entity that is designated as a 
        federally qualified health center under paragraph (1) shall not 
        be eligible for grants under this Act unless such entity 
        complies with the requirements of this Act, including serving 
        areas that are designated as medically underserved areas or 
        populations.

SEC. 4. GENERAL REQUIREMENTS.

    (a) Service Area.--To be eligible to receive a grant under section 
3, an entity shall agree to provide services to designated medically 
underserved populations within the service area of the entity.
    (b) Required Services.--
            (1) In general.--To be eligible to receive a grant under 
        section 3, an entity shall provide (directly or through 
        contracts or cooperative agreements) all of the required 
        services described in paragraph (2).
            (2) Required services.--Required services described in this 
        paragraph shall include--
                    (A) basic health services (services of health 
                professionals, diagnostic lab and radiology services, 
                preventive health services, emergency health services, 
                dental services, and pharmaceutical services);
                    (B) referrals to providers of medical and other 
                health-related services;
                    (C) patient case management services (as defined 
                for purposes of the Medicaid program under title XIX of 
                the Social Security Act (42 U.S.C. 1396 et seq.); and
                    (D) required enabling services (which may include 
                transportation, community and patient outreach, patient 
                education, and translation services).
            (3) Additional services.--
                    (A) In general.--An entity that receives a grant 
                under section 3 may provide any additional services 
                that are approved by the Secretary for inclusion in the 
                operating plan of the entity under section 5.
                    (B) Type of services.--Additional services under 
                this paragraph may include any item or service covered 
                under the Medicare, Medicaid, or SCHIP programs (under 
                titles XVIII, XIX, or XXI of the Social Security Act), 
                except for inpatient hospital or psychiatric services, 
                extended or intermediate care or nursing facility 
                services, residential mental health services, 
                environmental health services, and other enabling 
                services not otherwise required in this subsection.
    (c) Availability of Services.--
            (1) In general.--To be eligible to receive a grant under 
        section 3, an entity shall agree to make its services available 
        and accessible (subject only to capacity limitations) to all 
        individuals residing in the service area of the entity in a 
        manner that assures continuity, except that this subsection 
        shall not apply to entities that serve only migrant or seasonal 
        farmworkers, homeless individuals, or Indians.
            (2) Accessibility.--To be eligible to receive a grant under 
        section 3, an entity shall agree to carry out activities 
        designed to make services and care accessible to all homeless 
        persons, residents of public housing, and individuals with HIV, 
        tuberculosis or other communicable disease who are located 
        within the entity's service area.
    (d) Governing Boards.--To be eligible to receive a grant under 
section 3, an entity shall have a governing board--
            (1) a majority of whose members are receiving services 
        through the entity, except that such requirements shall not 
        apply to an entity that is operated by an Indian tribe or 
        tribal organization;
            (2) that meets at least quarterly;
            (3) that establishes general policies for the operations of 
        the entity;
            (4) that selects the director of the entity; and
            (5) that approves the entity's operating plan and 
        application for funds under section 3.
    (e) Quality Assurance Program and System.--To be eligible to 
receive a grant under section 3, an entity shall agree to maintain an 
ongoing quality assurance program and systems to protect the 
confidentiality of patient records.
    (f) Referral Relationship.--To be eligible to receive a grant under 
section 3, an entity shall agree to maintain an ongoing referral 
relationship with one or more hospitals.
    (g) Accounting.--To be eligible to receive a grant under section 3, 
an entity shall agree to comply with all Federal accounting procedures 
related to the funding received by such entity under this Act.
    (h) Fee and Discount Schedules, Participation in Programs.--To be 
eligible to receive a grant under section 3, an entity shall agree to--
            (1) establish a fee schedule that is consistent with 
        locally prevailing rates for similar services;
            (2) establish a schedule of discounts for patient payments 
        that is based on their ability to pay;
            (3) participate as a provider of services in the Medicare 
        and Medicaid program under title XVIII and XIX of the Social 
        Security Act, and under any other Federal or State health 
        insurance program; and
            (4) attempt to bill and collect payments for services 
        provided through the entity from patients (with discounts) and 
        from all third-party payers (without discounts).
    (i) Nondenial of Services.--To be eligible to receive a grant under 
section 3, an entity shall agree to not deny its services to any 
individual for failure to pay.
    (j) Cultural Context.--To be eligible to receive a grant under 
section 3, an entity shall agree to provide its services in the most 
appropriate cultural context for its patients.
    (k) Report.--To be eligible to receive a grant under section 3, an 
entity shall agree to submit in a timely manner all reports required 
under this Act concerning the activities of the entity under this 
grant, including reports on expenditures, utilization patterns, 
availability and acceptability of services, and its use of excess 
program income.
    (l) Continuity of Care.--To be eligible to receive a grant under 
section 3, an entity shall agree to continue to provide services to any 
medically underserved populations in its service area, and continue 
meeting all other requirements of this section during the period of the 
grant.

SEC. 5. OPERATING PLANS.

    (a) In General.--To be eligible to receive a grant under section 3, 
an entity shall submit, together with its application under section 
3(b)(3), a proposed operating plan that meets the requirements of this 
section for the fiscal year involved.
    (b) Requirements.--The proposed operating plan under subsection (a) 
shall--
            (1) include a complete operating budget for the entity, 
        including budgeting for the costs of--
                    (A) providing or arranging for all required 
                services and any additional services the entity has 
                received approval to provide;
                    (B) recruiting, training, and compensating all 
                employees of the entity;
                    (C) administering the entity (including the cost of 
                meeting all requirements, and the cost of participating 
                in one or more health plans); and
                    (D) carrying out any off-site activities involved 
                in providing or arranging for the required and 
                additional services in its operating plan;
            (2) describe the purposes for which the entity intends to 
        expend amounts received under the grant;
            (3) include a projection of the total amount that the 
        entity expects to receive during the fiscal year as payments 
        for the services it provides; and
            (4) in the case of an entity that is a public entity that 
        does not have governing boards that fully comply with section 
        4(d), include an agreement to provide non-Federal matching 
        funds in an amount equal to at least 50 percent of the 
        operating budget of the entity.
    (c) Additional Budgetary Information.--In addition to the 
information required in the proposed operating plan under subsection 
(b)(1), an entity may provide its proposed expenditures for--
            (1) providing new additional services for which the entity 
        is seeking approval;
            (2) expanding the capacity of the entity to serve new 
        patients;
            (3) developing and operating school-based clinics, mobile 
        clinics, satellite clinics, or off-site locations;
            (4) capital costs (including facilities and equipment), 
        subject to this Act; and
            (5) any other allowable costs.
    (d) Modifications to Plan.--The Secretary may approve modification 
to the operating plan or budget of an entity during a fiscal year if 
requested by the entity, and shall approve any such requested 
modifications that do not involve an increase in grant funds or that do 
not compromise the availability or accessibility of services provided 
through the entity.

SEC. 6. AMOUNT OF GRANTS.

    (a) Negotiations.--
            (1) In general.--Prior to approving the application of an 
        eligible entity under section 3(b)(3), the Secretary shall 
        enter into negotiations with such entity with respect to the 
        operating plan and budget contained in the application for the 
        fiscal year involved.
            (2) Requirements.--In conducting negotiations under 
        paragraph (1), the Secretary shall--
                    (A) develop and utilize criteria for determining 
                whether the requested expenditures of an entity may be 
                included in a entity's plan and budget, and whether any 
                limitations will apply to such expenditures;
                    (B) permit all proposed expenditures that are 
                allowable under part 413 of title 42, Code of Federal 
                Regulations (relating to determination of allowable 
                costs for purposes of federally qualified health center 
                reimbursement under Medicare and Medicaid under titles 
                XVIII and XIX of the Social Security Act), except that 
                no caps may be placed on any allowable expenditures; 
                and
                    (C) provide a written explanation of any 
                determinations concerning whether a requested 
                expenditure--
                            (i) is or is not allowable;
                            (ii) is limited in any way; and
                            (iii) is denied and, if the denied expense 
                        is for a requested additional service, whether 
                        the Secretary believes that the services is or 
                        is not needed by the center's patients.
            (3) Criteria.--The criteria developed under paragraph 
        (2)(A) shall ensure that the entity to which such criteria are 
        applied will be reasonably and efficiently administered, taking 
        into account the cost of recruiting and providing competitive 
        compensation to staff (including health professionals), the 
        higher costs of operating entities in rural or urban areas, the 
        higher cost of serving a population with greater health risks 
        or more severe health conditions, and the higher cost of 
        participating in health professions training programs.
    (b) Allowable Capital Costs.--
            (1) In general.--For purposes of subsection (a)(2)(B), 
        allowable capital costs shall include the costs of repaying 
        loans, as well as loan guarantees or interest subsidies, for 
        the acquisition, expansion, modernization, or construction (but 
        only if construction is the only available mechanism) of 
        buildings or for the purchase of equipment.
            (2) Federal interest.--The Federal Government shall 
        maintain an interest in any facility or equipment that is 
        purchased, expanded, modernized, or constructed with Federal 
        funds (in whole or in part) under this Act. Such Federal 
        interest may be subordinated or waived if such subordination or 
        waiver will further the objectives of this Act.
    (c) Amount.--The amount of grant awarded to an entity under this 
Act shall, subject to section 7, be equal to the amount by which the 
approved allowable costs of the entity (as determined by the Secretary 
based on the application and plan submitted by the entity) exceed the 
approved projection of payments that the entity expects to receive 
during the fiscal year as payments for the services provided by the 
entity during such year.
    (d) Non-Grant Funds.--Except as otherwise provided in this Act, the 
Secretary shall not restrict the expenditure by an entity of non-grant 
funds as provided for in the operating plan and budget of the entity, 
so long as such funds are expended for purposes that are consistent 
with this Act.
    (e) Reconciliation.--If, at the end of a fiscal year, the sum of 
the amount of the grant awarded to an entity under this Act for the 
fiscal year and the actual non-grant income of the entity exceeds the 
entity's costs in carrying out the approved operating plan for the 
year, the entity may retain such excess amount so long as the entity 
agrees to use such excess amount to--
            (1) expand and improve services;
            (2) increase the number of individuals served by the 
        entity;
            (3) purchase equipment;
            (4) acquire, expand, modernize, or construct facilities;
            (5) improve the administration of the entity;
            (6) establish financial reserves;
            (7) carry out health professions training programs; or
            (8) develop approvable health center-controlled networks.

SEC. 7. AUTHORIZATION OF APPROPRIATIONS; ALLOCATION OF FUNDS.

    (a) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this Act such sums as may be necessary for 
each of fiscal years 2009 through 2015.
    (b) Nature of Grant.--With respect to the purposes for which a 
grant under section 3(a) is authorized to be expended, modifications in 
such purposes enacted after the date of the enactment of this Act shall 
not affect the amount of appropriations authorized under subsection (a) 
for any fiscal year.
    (c) Allocations for Unanticipated Needs.--
            (1) In general.--Of the amount appropriated for each fiscal 
        year under subsection (a), the Secretary shall reserve 2 
        percent of such amount for awarding grants to any grantees 
        under this Act that, in the determination of the Secretary, has 
        a need for such a grant to assist the grantee in responding to 
        unanticipated needs for required services or additional 
        services that have arisen in the service area of the grantee, 
        or in responding to other unanticipated circumstances that have 
        arisen in the provision by the grantee of required services or 
        additional services.
            (2) Allocation of unobligated amounts.--With respect to 
        amounts that are reserved under paragraph (1) for a fiscal year 
        and that are unobligated as of September 30 of such fiscal year 
        (referred to in this paragraph as the ``unobligated balance''), 
        the Secretary shall pay to each grantee under this Act, from 
        such unobligated balance, an amount equal to the product of 
        such balance and the percentage constituted by the ratio of the 
        amount of the grant for the fiscal year for such grantee under 
        this Act to the sum of the total amount of grants under this 
        Act for the year. The amount paid to such grantee under the 
        preceding sentence shall be considered by the Secretary to be 
        part of the grant made for such fiscal year to the grantee 
        under section 3.

SEC. 8. NATIONAL HEALTH SERVICE CORPS.

    Section 338H(a) of the Public Health Service Act (42 U.S.C. 
254q(a)) is amended to read as follows:
    ``(a) Authorization of Appropriations.--For the purposes of 
carrying out this subpart, there are authorized to be appropriated such 
sums as may be necessary for each of fiscal years 2009 through 2015.''.
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