[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3483 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 3483

 To reform the medical liability system, improve access to health care 
     for rural and indigent patients, enhance access to affordable 
              prescription drugs, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 31, 2009

  Mr. Heller introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
 To reform the medical liability system, improve access to health care 
     for rural and indigent patients, enhance access to affordable 
              prescription drugs, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Steps Toward 
Access and Reform Act of 2009'' or the ``STAR Act of 2009''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
                   TITLE I--MEDICAL LIABILITY REFORM

Sec. 101. Encouraging speedy resolution of claims.
Sec. 102. Compensating patient injury.
Sec. 103. Maximizing patient recovery.
Sec. 104. Additional collateral source benefits.
Sec. 105. Punitive damages.
Sec. 106. Authorization of payment of future damages to claimants in 
                            health care lawsuits.
Sec. 107. Effect on other laws.
Sec. 108. State flexibility and protection of States' rights.
Sec. 109. Applicability; effective date.
Sec. 110. Sense of Congress.
Sec. 111. Definitions.
       TITLE II--IMPROVING ACCESS FOR RURAL AND INDIGENT PATIENTS

Sec. 201. Improving access for rural and indigent patients.
    TITLE III--PROMOTING AFFORDABLE PRESCRIPTION DRUGS BY DEFINING 
             OBJECTIVES IN NEGOTIATION OF TRADE AGREEMENTS

Sec. 301. Promoting affordable prescription drugs by defining 
                            objectives in negotiation of trade 
                            agreements.
                TITLE IV--ENCOURAGING PREVENTATIVE CARE

Sec. 401. Encouraging preventative care.

                   TITLE I--MEDICAL LIABILITY REFORM

SEC. 101. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

    The time for the commencement of a health care lawsuit shall be 3 
years after the date of manifestation of injury or 1 year after the 
claimant discovers, or through the use of reasonable diligence should 
have discovered, the injury, whichever occurs first. In no event shall 
the time for commencement of a health care lawsuit exceed 3 years after 
the date of manifestation of injury unless tolled for any of the 
following--
            (1) upon proof of fraud;
            (2) intentional concealment; or
            (3) the presence of a foreign body, which has no 
        therapeutic or diagnostic purpose or effect, in the body of the 
        injured person.
Actions by a minor shall be commenced within 3 years from the date of 
the alleged manifestation of injury except that actions by a minor 
under the full age of 6 years shall be commenced within 3 years of 
manifestation of injury or prior to the minor's 8th birthday, whichever 
provides a longer period. Such time limitation shall be tolled for 
minors for any period during which a parent or guardian and a health 
care provider or health care organization have committed fraud or 
collusion in the failure to bring an action on behalf of the injured 
minor.

SEC. 102. COMPENSATING PATIENT INJURY.

    (a) Unlimited Amount of Damages for Actual Economic Losses in 
Health Care Lawsuits.--In any health care lawsuit, nothing in this 
title shall limit a claimant's recovery of the full amount of the 
available economic damages, notwithstanding the limitation in 
subsection (b).
    (b) Additional Noneconomic Damages.--In any health care lawsuit, 
the amount of noneconomic damages, if available, shall not exceed 
$250,000, regardless of the number of parties against whom the action 
is brought or the number of separate claims or actions brought with 
respect to the same injury.
    (c) No Discount of Award for Noneconomic Damages.--For purposes of 
applying the limitation in subsection (b), future noneconomic damages 
shall not be discounted to present value. The jury shall not be 
informed about the maximum award for noneconomic damages. An award for 
noneconomic damages in excess of $250,000 shall be reduced either 
before the entry of judgment, or by amendment of the judgment after 
entry of judgment, and such reduction shall be made before accounting 
for any other reduction in damages required by law. If separate awards 
are rendered for past and future noneconomic damages and the combined 
awards exceed $250,000, the future noneconomic damages shall be reduced 
first.
    (d) Fair Share Rule.--In any health care lawsuit, each party shall 
be liable for that party's several share of any damages only and not 
for the share of any other person. Each party shall be liable only for 
the amount of damages allocated to such party in direct proportion to 
such party's percentage of responsibility. Whenever a judgment of 
liability is rendered as to any party, a separate judgment shall be 
rendered against each such party for the amount allocated to such 
party. For purposes of this section, the trier of fact shall determine 
the proportion of responsibility of each party for the claimant's harm.

SEC. 103. MAXIMIZING PATIENT RECOVERY.

    (a) Court Supervision of Share of Damages Actually Paid to 
Claimants.--In any health care lawsuit, the court shall supervise the 
arrangements for payment of damages to protect against conflicts of 
interest that may have the effect of reducing the amount of damages 
awarded that are actually paid to claimants. In particular, in any 
health care lawsuit in which the attorney for a party claims a 
financial stake in the outcome by virtue of a contingent fee, the court 
shall have the power to restrict the payment of a claimant's damage 
recovery to such attorney, and to redirect such damages to the claimant 
based upon the interests of justice and principles of equity. In no 
event shall the total of all contingent fees for representing all 
claimants in a health care lawsuit exceed the following limits:
            (1) 40 percent of the first $50,000 recovered by the 
        claimants.
            (2) 33\1/3\ percent of the next $50,000 recovered by the 
        claimants.
            (3) 25 percent of the next $500,000 recovered by the 
        claimants.
            (4) 15 percent of any amount by which the recovery by the 
        claimants is in excess of $600,000.
    (b) Applicability.--The limitations in this section shall apply 
whether the recovery is by judgment, settlement, mediation, 
arbitration, or any other form of alternative dispute resolution. In a 
health care lawsuit involving a minor or incompetent person, a court 
retains the authority to authorize or approve a fee that is less than 
the maximum permitted under this section. The requirement for court 
supervision in the first two sentences of subsection (a) applies only 
in civil actions.

SEC. 104. ADDITIONAL COLLATERAL SOURCE BENEFITS.

    In any health care lawsuit involving injury or wrongful death, any 
party may introduce evidence of collateral source benefits. If a party 
elects to introduce such evidence, any opposing party may introduce 
evidence of any amount paid or contributed or reasonably likely to be 
paid or contributed in the future by or on behalf of the opposing party 
to secure the right to such collateral source benefits. No provider of 
collateral source benefits shall recover any amount against the 
claimant or receive any lien or credit against the claimant's recovery 
or be equitably or legally subrogated to the right of the claimant in a 
health care lawsuit involving injury or wrongful death. This section 
shall apply to any health care lawsuit that is settled as well as a 
health care lawsuit that is resolved by a fact finder. This section 
shall not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section 
1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security Act.

SEC. 105. PUNITIVE DAMAGES.

    (a) In General.--Punitive damages may, if otherwise permitted by 
applicable State or Federal law, be awarded against any person in a 
health care lawsuit only if it is proven by clear and convincing 
evidence that such person acted with malicious intent to injure the 
claimant, or that such person deliberately failed to avoid unnecessary 
injury that such person knew the claimant was substantially certain to 
suffer. In any health care lawsuit where no judgment for compensatory 
damages is rendered against such person, no punitive damages may be 
awarded with respect to the claim in such lawsuit. No demand for 
punitive damages shall be included in a health care lawsuit as 
initially filed. A court may allow a claimant to file an amended 
pleading for punitive damages only upon a motion by the claimant and 
after a finding by the court, upon review of supporting and opposing 
affidavits or after a hearing, after weighing the evidence, that the 
claimant has established by a substantial probability that the claimant 
will prevail on the claim for punitive damages. At the request of any 
party in a health care lawsuit, the trier of fact shall consider in a 
separate proceeding--
            (1) whether punitive damages are to be awarded and the 
        amount of such award; and
            (2) the amount of punitive damages following a 
        determination of punitive liability.
If a separate proceeding is requested, evidence relevant only to the 
claim for punitive damages, as determined by applicable State law, 
shall be inadmissible in any proceeding to determine whether 
compensatory damages are to be awarded.
    (b) Determining Amount of Punitive Damages.--
            (1) Factors considered.--In determining the amount of 
        punitive damages, if awarded, in a health care lawsuit, the 
        trier of fact shall consider only the following--
                    (A) the severity of the harm caused by the conduct 
                of such party;
                    (B) the duration of the conduct or any concealment 
                of it by such party;
                    (C) the profitability of the conduct to such party;
                    (D) the number of products sold or medical 
                procedures rendered for compensation, as the case may 
                be, by such party, of the kind causing the harm 
                complained of by the claimant;
                    (E) any criminal penalties imposed on such party, 
                as a result of the conduct complained of by the 
                claimant; and
                    (F) the amount of any civil fines assessed against 
                such party as a result of the conduct complained of by 
                the claimant.
            (2) Maximum award.--The amount of punitive damages, if 
        awarded, in a health care lawsuit may not exceed $250,000 or 
        two times the amount of economic damages awarded, whichever is 
        greater. The jury shall not be informed of this limitation.
    (c) No Punitive Damages for Products That Comply With FDA 
Standards.--
            (1) In general.--
                    (A) No punitive damages may be awarded against the 
                manufacturer or distributor of a medical product, or a 
                supplier of any component or raw material of such 
                medical product, based on a claim that such product 
                caused the claimant's harm where--
                            (i)(I) such medical product was subject to 
                        premarket approval, clearance, or licensure by 
                        the Food and Drug Administration with respect 
                        to the safety of the formulation or performance 
                        of the aspect of such medical product which 
                        caused the claimant's harm or the adequacy of 
                        the packaging or labeling of such medical 
                        product; and
                            (II) such medical product was so approved, 
                        cleared, or licensed; or
                            (ii) such medical product is generally 
                        recognized among qualified experts as safe and 
                        effective pursuant to conditions established by 
                        the Food and Drug Administration and applicable 
                        Food and Drug Administration regulations, 
                        including without limitation those related to 
                        packaging and labeling, unless the Food and 
                        Drug Administration has determined that such 
                        medical product was not manufactured or 
                        distributed in substantial compliance with 
                        applicable Food and Drug Administration 
                        statutes and regulations.
                    (B) Rule of construction.--Subparagraph (A) may not 
                be construed as establishing the obligation of the Food 
                and Drug Administration to demonstrate affirmatively 
                that a manufacturer, distributor, or supplier referred 
                to in such subparagraph meets any of the conditions 
                described in such subparagraph.
            (2) Liability of health care providers.--A health care 
        provider who prescribes, or who dispenses pursuant to a 
        prescription, a medical product approved, licensed, or cleared 
        by the Food and Drug Administration shall not be named as a 
        party to a product liability lawsuit involving such product and 
        shall not be liable to a claimant in a class action lawsuit 
        against the manufacturer, distributor, or seller of such 
        product. Nothing in this paragraph prevents a court from 
        consolidating cases involving health care providers and cases 
        involving products liability claims against the manufacturer, 
        distributor, or product seller of such medical product.
            (3) Packaging.--In a health care lawsuit for harm which is 
        alleged to relate to the adequacy of the packaging or labeling 
        of a drug which is required to have tamper-resistant packaging 
        under regulations of the Secretary of Health and Human Services 
        (including labeling regulations related to such packaging), the 
        manufacturer or product seller of the drug shall not be held 
        liable for punitive damages unless such packaging or labeling 
        is found by the trier of fact by clear and convincing evidence 
        to be substantially out of compliance with such regulations.
            (4) Exception.--Paragraph (1) shall not apply in any health 
        care lawsuit in which--
                    (A) a person, before or after premarket approval, 
                clearance, or licensure of such medical product, 
                knowingly misrepresented to or withheld from the Food 
                and Drug Administration information that is required to 
                be submitted under the Federal Food, Drug, and Cosmetic 
                Act (21 U.S.C. 301 et seq.) or section 351 of the 
                Public Health Service Act (42 U.S.C. 262) that is 
                material and is causally related to the harm which the 
                claimant allegedly suffered; or
                    (B) a person made an illegal payment to an official 
                of the Food and Drug Administration for the purpose of 
                either securing or maintaining approval, clearance, or 
                licensure of such medical product.

SEC. 106. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO CLAIMANTS IN 
              HEALTH CARE LAWSUITS.

    (a) In General.--In any health care lawsuit, if an award of future 
damages, without reduction to present value, equaling or exceeding 
$50,000 is made against a party with sufficient insurance or other 
assets to fund a periodic payment of such a judgment, the court shall, 
at the request of any party, enter a judgment ordering that the future 
damages be paid by periodic payments. In any health care lawsuit, the 
court may be guided by the Uniform Periodic Payment of Judgments Act 
promulgated by the National Conference of Commissioners on Uniform 
State Laws.
    (b) Applicability.--This section applies to all actions which have 
not been first set for trial or retrial before the effective date of 
this Act.

SEC. 107. EFFECT ON OTHER LAWS.

    (a) Vaccine Injury.--
            (1) To the extent that title XXI of the Public Health 
        Service Act establishes a Federal rule of law applicable to a 
        civil action brought for a vaccine-related injury or death--
                    (A) this title does not affect the application of 
                the rule of law to such an action; and
                    (B) any rule of law prescribed by this title in 
                conflict with a rule of law of such title XXI shall not 
                apply to such action.
            (2) If there is an aspect of a civil action brought for a 
        vaccine-related injury or death to which a Federal rule of law 
        under title XXI of the Public Health Service Act does not 
        apply, then this title or otherwise applicable law (as 
        determined under this title) will apply to such aspect of such 
        action.
    (b) Other Federal Law.--Except as provided in this section, nothing 
in this title shall be deemed to affect any defense available to a 
defendant in a health care lawsuit or action under any other provision 
of Federal law.

SEC. 108. STATE FLEXIBILITY AND PROTECTION OF STATES' RIGHTS.

    (a) Health Care Lawsuits.--The provisions governing health care 
lawsuits set forth in this title preempt, subject to subsections (b) 
and (c), State law to the extent that State law prevents the 
application of any provisions of law established by or under this 
title. The provisions governing health care lawsuits set forth in this 
title supersede chapter 171 of title 28, United States Code, to the 
extent that such chapter--
            (1) provides for a greater amount of damages or contingent 
        fees, a longer period in which a health care lawsuit may be 
        commenced, or a reduced applicability or scope of periodic 
        payment of future damages, than provided in this title; or
            (2) prohibits the introduction of evidence regarding 
        collateral source benefits, or mandates or permits subrogation 
        or a lien on collateral source benefits.
    (b) Protection of States' Rights and Other Laws.--(1) Any issue 
that is not governed by any provision of law established by or under 
this title (including State standards of negligence) shall be governed 
by otherwise applicable State or Federal law.
    (2) This title shall not preempt or supersede any State or Federal 
law that imposes greater procedural or substantive protections for 
health care providers and health care organizations from liability, 
loss, or damages than those provided by this title or create a cause of 
action.
    (c) State Flexibility.--No provision of this title shall be 
construed to preempt--
            (1) any State law (whether effective before, on, or after 
        the date of the enactment of this Act) that specifies a 
        particular monetary amount of compensatory or punitive damages 
        (or the total amount of damages) that may be awarded in a 
        health care lawsuit, regardless of whether such monetary amount 
        is greater or lesser than is provided for under this title, 
        notwithstanding section 104(a); or
            (2) any defense available to a party in a health care 
        lawsuit under any other provision of State or Federal law.

SEC. 109. APPLICABILITY; EFFECTIVE DATE.

    This title shall apply to any health care lawsuit brought in a 
Federal or State court, or subject to an alternative dispute resolution 
system, that is initiated on or after the date of the enactment of this 
Act, except that any health care lawsuit arising from an injury 
occurring prior to the date of the enactment of this Act shall be 
governed by the applicable statute of limitations provisions in effect 
at the time the injury occurred.

SEC. 110. SENSE OF CONGRESS.

    It is the sense of Congress that a health insurer should be liable 
for damages for harm caused when it makes a decision as to what care is 
medically necessary and appropriate.

SEC. 111. DEFINITIONS.

    In this title:
            (1) Alternative dispute resolution system; adr.--The term 
        ``alternative dispute resolution system'' or ``ADR'' means a 
        system that provides for the resolution of health care lawsuits 
        in a manner other than through a civil action brought in a 
        State or Federal court.
            (2) Claimant.--The term ``claimant'' means any person who 
        brings a title, including a person who asserts or claims a 
        right to legal or equitable contribution, indemnity, or 
        subrogation, arising out of a health care liability claim or 
        action, and any person on whose behalf such a claim is asserted 
        or such an action is brought, whether deceased, incompetent, or 
        a minor.
            (3) Collateral source benefits.--The term ``collateral 
        source benefits'' means any amount paid or reasonably likely to 
        be paid in the future to or on behalf of the claimant, or any 
        service, product, or other benefit provided or reasonably 
        likely to be provided in the future to or on behalf of the 
        claimant, as a result of the injury or wrongful death, pursuant 
        to--
                    (A) any State or Federal health, sickness, income-
                disability, accident, or workers' compensation law;
                    (B) any health, sickness, income-disability, or 
                accident insurance that provides health benefits or 
                income-disability coverage;
                    (C) any contract or agreement of any group, 
                organization, partnership, or corporation to provide, 
                pay for, or reimburse the cost of medical, hospital, 
                dental, or income-disability benefits; and
                    (D) any other publicly or privately funded program.
            (4) Compensatory damages.--The term ``compensatory 
        damages'' means objectively verifiable monetary losses incurred 
        as a result of the provision of, use of, or payment for (or 
        failure to provide, use, or pay for) health care services or 
        medical products, such as past and future medical expenses, 
        loss of past and future earnings, cost of obtaining domestic 
        services, loss of employment, and loss of business or 
        employment opportunities, damages for physical and emotional 
        pain, suffering, inconvenience, physical impairment, mental 
        anguish, disfigurement, loss of enjoyment of life, loss of 
        society and companionship, loss of consortium (other than loss 
        of domestic service), hedonic damages, injury to reputation, 
        and all other nonpecuniary losses of any kind or nature. The 
        term ``compensatory damages'' includes economic damages and 
        noneconomic damages, as such terms are defined in this section.
            (5) Contingent fee.--The term ``contingent fee'' includes 
        all compensation to any person or persons which is payable only 
        if a recovery is effected on behalf of one or more claimants.
            (6) Economic damages.--The term ``economic damages'' means 
        objectively verifiable monetary losses incurred as a result of 
        the provision of, use of, or payment for (or failure to 
        provide, use, or pay for) health care services or medical 
        products, such as past and future medical expenses, loss of 
        past and future earnings, cost of obtaining domestic services, 
        loss of employment, and loss of business or employment 
        opportunities.
            (7) Health care lawsuit.--The term ``health care lawsuit'' 
        means any health care liability claim concerning the provision 
        of health care goods or services or any medical product 
        affecting interstate commerce, or any health care liability 
        action concerning the provision of health care goods or 
        services or any medical product affecting interstate commerce, 
        brought in a State or Federal court or pursuant to an 
        alternative dispute resolution system, against a health care 
        provider, a health care organization, or the manufacturer, 
        distributor, supplier, marketer, promoter, or seller of a 
        medical product, regardless of the theory of liability on which 
        the claim is based, or the number of claimants, plaintiffs, 
        defendants, or other parties, or the number of claims or causes 
        of action, in which the claimant alleges a health care 
        liability claim. Such term does not include a claim or action 
        which is based on criminal liability; which seeks civil fines 
        or penalties paid to Federal, State, or local government; or 
        which is grounded in antitrust.
            (8) Health care liability action.--The term ``health care 
        liability action'' means a civil action brought in a State or 
        Federal court or pursuant to an alternative dispute resolution 
        system, against a health care provider, a health care 
        organization, or the manufacturer, distributor, supplier, 
        marketer, promoter, or seller of a medical product, regardless 
        of the theory of liability on which the claim is based, or the 
        number of plaintiffs, defendants, or other parties, or the 
        number of causes of action, in which the claimant alleges a 
        health care liability claim.
            (9) Health care liability claim.--The term ``health care 
        liability claim'' means a demand by any person, whether or not 
        pursuant to ADR, against a health care provider, health care 
        organization, or the manufacturer, distributor, supplier, 
        marketer, promoter, or seller of a medical product, including, 
        but not limited to, third-party claims, cross-claims, counter-
        claims, or contribution claims, which are based upon the 
        provision of, use of, or payment for (or the failure to 
        provide, use, or pay for) health care services or medical 
        products, regardless of the theory of liability on which the 
        claim is based, or the number of plaintiffs, defendants, or 
        other parties, or the number of causes of action.
            (10) Health care organization.--The term ``health care 
        organization'' means any person or entity which is obligated to 
        provide or pay for health benefits under any health plan, 
        including any person or entity acting under a contract or 
        arrangement with a health care organization to provide or 
        administer any health benefit.
            (11) Health care provider.--The term ``health care 
        provider'' means any person or entity required by State or 
        Federal laws or regulations to be licensed, registered, or 
        certified to provide health care services, and being either so 
        licensed, registered, or certified, or exempted from such 
        requirement by other statute or regulation.
            (12) Health care goods or services.--The term ``health care 
        goods or services'' means any goods or services provided by a 
        health care organization, provider, or by any individual 
        working under the supervision of a health care provider, that 
        relates to the diagnosis, prevention, or treatment of any human 
        disease or impairment, or the assessment or care of the health 
        of human beings.
            (13) Malicious intent to injure.--The term ``malicious 
        intent to injure'' means intentionally causing or attempting to 
        cause physical injury other than providing health care goods or 
        services.
            (14) Medical product.--The term ``medical product'' means a 
        drug, device, or biological product intended for humans, and 
        the terms ``drug'', ``device'', and ``biological product'' have 
        the meanings given such terms in sections 201(g)(1) and 201(h) 
        of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 321(g)(1) 
        and (h)) and section 351(a) of the Public Health Service Act 
        (42 U.S.C. 262(a)), respectively, including any component or 
        raw material used therein, but excluding health care services.
            (15) Noneconomic damages.--The term ``noneconomic damages'' 
        means damages for physical and emotional pain, suffering, 
        inconvenience, physical impairment, mental anguish, 
        disfigurement, loss of enjoyment of life, loss of society and 
        companionship, loss of consortium (other than loss of domestic 
        service), hedonic damages, injury to reputation, and all other 
        nonpecuniary losses of any kind or nature.
            (16) Punitive damages.--The term ``punitive damages'' means 
        damages awarded, for the purpose of punishment or deterrence, 
        and not solely for compensatory purposes, against a health care 
        provider, health care organization, or a manufacturer, 
        distributor, or supplier of a medical product. Punitive damages 
        are neither economic nor noneconomic damages.
            (17) Recovery.--The term ``recovery'' means the net sum 
        recovered after deducting any disbursements or costs incurred 
        in connection with prosecution or settlement of the claim, 
        including all costs paid or advanced by any person. Costs of 
        health care incurred by the plaintiff and the attorneys' office 
        overhead costs or charges for legal services are not deductible 
        disbursements or costs for such purpose.
            (18) State.--The term ``State'' means each of the several 
        States, the District of Columbia, the Commonwealth of Puerto 
        Rico, the Virgin Islands, Guam, American Samoa, the Northern 
        Mariana Islands, the Trust Territory of the Pacific Islands, 
        and any other territory or possession of the United States, or 
        any political subdivision thereof.

       TITLE II--IMPROVING ACCESS FOR RURAL AND INDIGENT PATIENTS

SEC. 201. IMPROVING ACCESS FOR RURAL AND INDIGENT PATIENTS.

    (a) Loan Forgiveness for Primary Care Providers.--
            (1) In general.--The Secretary of Health and Human Services 
        shall carry out a program of entering into contracts with 
        eligible individuals under which--
                    (A) the individual agrees to serve for a period of 
                not less than 4 years as a primary care provider in a 
                medically underserved community (as defined in section 
                799B of the Public Health Service Act (42 U.S.C. 
                295p)); and
                    (B) in consideration of such service, the Secretary 
                agrees to pay not more than $100,000 on the principal 
                and interest on the individual's graduate educational 
                loans.
            (2) Eligibility.--To be eligible to enter into a contract 
        under subsection (1), an individual must--
                    (A) have a graduate degree in medicine, osteopathic 
                medicine, or another health profession from an 
                accredited (as determined by the Secretary of Health 
                and Human Services) institution of higher education; 
                and
                    (B) have practiced as a primary care provider for a 
                period (excluding any residency or fellowship training 
                period) of not less than 3 years in a medically 
                underserved community (as defined in section 799B of 
                the Public Health Service Act (42 U.S.C. 295p)).
            (3) Installments.--Payments under this section may be made 
        in installments of not more than $25,000 for each year of 
        service described in paragraph (1) (A).
            (4) Applicability of certain provisions.--The provisions of 
        subpart III of part D of title III of the Public Health Service 
        Act shall, except as inconsistent with this section, apply to 
        the program established under this section in the same manner 
        and to the same extent as such provisions apply to the National 
        Health Service Corps Loan Repayment Program established in such 
        subpart.
    (b) Permitting State Designation of Critical Access Hospitals.--
Section 1820(c)(2)(B)(i)(II) of the Social Security Act (42 U.S.C. 
1395i-4(c)(2)(B)(i)(II)) is amended by inserting ``or on or after the 
date of enactment of the Steps Toward Access and Reform Act of 2009'' 
after ``January 1, 2006,''.
    (c) Patient Fairness and Indigent Care Promotion.--
            (1) In general.--Section 166 of the Internal Revenue Code 
        of 1986 (relating to bad debts) is amended by redesignating 
        subsection (f) as subsection (g) and by inserting after 
        subsection (e) the following new subsection:
    ``(f) Unpaid Medical Care Provided to Low-Income Individuals.--
            ``(1) In general.--In the case of a taxpayer to whom this 
        subsection applies, the deduction under subsection (a) for 
        worthless qualified medical care debt shall not be less than 75 
        percent of the taxpayer's charge for such care.
            ``(2) Taxpayer to whom subsection applies.--This subsection 
        shall apply to any taxpayer who is engaged in the trade or 
        business of providing medical care other than as an employee 
        and who used the cash receipts and disbursements method of 
        accounting.
            ``(3) Qualified medical care debt.--For purposes of this 
        subsection, the term `qualified medical care debt' means any 
        debt for medical care provided by the taxpayer to a low-income 
        individual who is a citizen or legal resident of the United 
        States.
            ``(4) Determination of charge.--The amount of the 
        taxpayer's charge which may be taken into account--
                    ``(A) shall not exceed the amount of the charge 
                that would be recognized for purposes of title XVIII of 
                the Social Security Act, and
                    ``(B) shall not include any amount for which the 
                taxpayer is not entitled to reimbursement from the low-
                income individual.
            ``(5) Low-income individual.--For purposes of this 
        subsection, the term `low-income individual' means an 
        individual who, at the time the medical care attributable to 
        the debt is provided, has an annual household income below 135 
        percent of the poverty line (as defined in section 673 of the 
        Community Services Block Grant Act (42 U.S.C. 9902)) applicable 
        to the size of the family involved, and is a citizen or legal 
        resident of the United States.
            ``(6) Medical care.--For purposes of this subsection, the 
        term `medical care' has the meaning given to such term by 
        section 213(d).
            ``(7) Regulations.--The Secretary shall prescribe such 
        regulations as may be necessary or appropriate to carry out 
        this section, including regulations providing for methods of 
        establishing that an individual is a low-income individual for 
        purposes of this section.''
            (2) Effective date.--The amendment made by this section 
        shall apply to taxable years beginning after the date of the 
        enactment of this Act.

    TITLE III--PROMOTING AFFORDABLE PRESCRIPTION DRUGS BY DEFINING 
             OBJECTIVES IN NEGOTIATION OF TRADE AGREEMENTS

SEC. 301. PROMOTING AFFORDABLE PRESCRIPTION DRUGS BY DEFINING 
              OBJECTIVES IN NEGOTIATION OF TRADE AGREEMENTS.

    (a) In General.--Section 2102(a) of the Bipartisan Trade Promotion 
Authority Act of 2002 (19 U.S.C. 3802(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (8);
            (2) by striking the period at the end of paragraph (9) and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(10) to avoid negotiating trade agreements that could 
        restrict, or be interpreted to restrict, the access of 
        consumers in the United States to pharmaceutical imports from 
        countries with a pharmaceutical infrastructure that is 
        equivalent, or superior, to that of the United States--
                    ``(A) by or through the use and development of the 
                doctrine of international patent exhaustion, as 
                interpreted or applied by United States courts on the 
                date of enactment of this Act; or
                    ``(B) by making it a violation for the United 
                States to enact legislation permitting pharmaceutical 
                imports without the consent of patent owners when the 
                products involved have been sold outside the United 
                States.''.
    (b) Certain Prohibitions.--Notwithstanding any other provision of 
law, the United States Trade Representative--
            (1) may not enter into a bilateral or multilateral trade 
        agreement that, with respect to the importation of 
        pharmaceutical products without the consent of the patent 
        owners, includes provisions that are the same or similar to the 
        provisions of--
                    (A) paragraph 2 of Article 16.7 of the United 
                States-Singapore Free Trade Agreement;
                    (B) paragraph 4 of Article 17.9 of the United 
                States-Australia Free Trade Agreement; or
                    (C) paragraph 4 of Article 15.9 of the United 
                States-Morocco Free Trade Agreement; and
            (2) may not, with respect to the importation of 
        pharmaceutical products without the consent of the patent 
        owners, negotiate an agreement or understanding with respect to 
        any of the provisions referred to in paragraph (1).

                TITLE IV--ENCOURAGING PREVENTATIVE CARE

SEC. 401. ENCOURAGING PREVENTATIVE CARE.

    (a) Mobile Mammography Promotion.--
            (1) Refunds.--Section 6427 of the Internal Revenue Code of 
        1986 (relating to fuels not used for taxable purposes) is 
        amended by inserting after subsection (f) the following new 
        subsection:
    ``(g) Fuels Used in Mobile Mammography Vehicles.--Except as 
provided in subsection (k), if any fuel on which tax was imposed by 
section 4041 or 4081 is used in any highway vehicle designed 
exclusively to provide mobile mammography services to patients within 
such vehicle, the Secretary shall pay (without interest) to the 
ultimate purchaser of such fuel an amount equal to the aggregate amount 
of the tax imposed on such fuel.''.
            (2) Exemption from retail tax.--Section 4041 of such Code 
        is amended by adding at the end the following new subsection:
    ``(n) Fuels Used in Mobile Mammography Vehicles.--No tax shall be 
imposed under this section on any liquid sold for use in, or used in, 
any highway vehicle designed exclusively to provide mobile mammography 
services to patients within such vehicle.''.
            (3) Effective date.--The amendments made by this section 
        shall take effect on the date of the enactment of this Act.
    (b) Medicare Lung Cancer Early Detection.--Section 1834 of the 
Social Security Act (42 U.S.C. 1395m) is amended--
            (1) in subsection (b)(1)(B), by striking ``subsection 
        (c)(1)(A)'' and inserting ``subsections (c)(1)(A) and (n)''; 
        and
            (2) by adding at the end the following new subsection:
    ``(n) Payment for Chest Radiography Services That Use Computer 
Aided Detection Technology for the Early Detection of Lung Cancer.--
            ``(1) In general.--Notwithstanding any other provision of 
        this part, with respect to chest radiography services 
        (identified as of September 1, 2006, by HCPCS codes 71010, 
        71020, 71021, 71022, and 71030, and as subsequently modified by 
        the Secretary) furnished on or after January 1, 2010, that use 
        Computer Aided Detection technology for the early detection of 
        lung cancer (as defined in paragraph (4)), the amount of 
        payment shall be equal to--
                    ``(A) with respect to the technical component of 
                such services--
                            ``(i) the amount of payment under the fee 
                        schedule established under section 1848 for 
                        such component for the year that would 
                        otherwise apply; plus
                            ``(ii) the amount described in paragraph 
                        (2); and
                    ``(B) with respect to the professional component of 
                such services--
                            ``(i) the amount of payment under the fee 
                        schedule established under section 1848 for 
                        such component for the year that would 
                        otherwise apply; plus
                            ``(ii) the amount described in paragraph 
                        (3).
            ``(2) Amount described for technical component.--The amount 
        described in this paragraph for services furnished--
                    ``(A) during 2010 is $12; or
                    ``(B) during a subsequent year is the amount 
                established under this paragraph for the preceding 
                year, increased by the update determined under section 
                1848(d) for the year.
            ``(3) Amount described for professional component.--The 
        amount described in this paragraph for services furnished--
                    ``(A) during 2010 is $4; and
                    ``(B) during a subsequent year is the amount 
                established under this paragraph for the preceding year 
                increased by the update determined under section 
                1848(d) for the year.
            ``(4) Computer aided detection technology for the early 
        detection of lung cancer defined.--In this subsection, the term 
        `Computer Aided Detection technology for the early detection of 
        lung cancer' means a computer software technology which allows 
        for the production of a digital chest x-ray image or the 
        conversion of a chest x-ray into a digital image to be 
        subsequently analyzed for early lung cancer nodules and which 
        the Food and Drug Administration has granted approval or 
        clearance.
            ``(5) New codes.--The Secretary shall establish new codes 
        for chest radiography services described in paragraph (1) in 
        order to implement this subsection.''.
    (c) Veterans Travel Tax Relief.--
            (1) In general.--Part VII of subchapter B of chapter I of 
        the Internal Revenue Code of 1986 (relating to additional 
        itemized deductions for individuals) is amended by 
        redesignating section 224 as section 225, and by inserting 
        after section 223 the following new section:

``SEC. 224. TRAVEL EXPENSES OF VETERANS FOR HEALTH CARE AT MEDICAL 
              CENTERS OF THE DEPARTMENT OF VETERANS AFFAIRS.

    ``(a) Allowance of Deduction.--In the case of an individual, there 
shall be allowed as a deduction the qualified travel expenses for the 
taxable year.
    ``(b) Limitations.--
            ``(1) Dollar limitation.--The amount allowed as a deduction 
        under subsection (a) for a taxable year shall not exceed $400.
            ``(2) Limitation based on adjusted gross income.--The 
        amount allowable as a deduction under subsection (a) shall be 
        reduced (but not below zero) by an amount which bears the same 
        ratio to the amount so allowable (determined without regard to 
        this paragraph but with regard to paragraph (1)) as--
                    ``(A) the amount (if any) by which the taxpayer's 
                adjusted gross income exceeds $75,000 ($150,000 in the 
                case of a joint return), bears to
                    ``(B) $10,000 ($20,000 in the case of a joint 
                return).
            ``(3) Adjustments for inflation.--In the case of a taxable 
        year beginning after 2009, each of the dollar amounts in 
        paragraph (2) shall be increased by an amount equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost-of-living adjustment determined 
                under section 1(f)(3) for the calendar year in which 
                the taxable year begins, determined by substituting 
                `calendar year 2008' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any amount as increased under the preceding sentence is not 
        a multiple of $100, such amount shall be rounded to the nearest 
        multiple of $100.
    ``(c) Qualified Travel Expenses.--For purposes of this section--
            ``(1) In general.--The term `qualified travel expenses' 
        means amounts paid for travel expenses of a veteran and a 
        family member of the veteran to a medical center of the 
        Department of Veterans Affairs for--
                    ``(A) treatment relating to a service-connected 
                disability, or
                    ``(B) examination conducted by the Secretary of 
                Veterans Affairs relating to a claim for disability 
                compensation or pension under the laws administered by 
                the Secretary of Veterans Affairs.
            ``(2) Reimbursements by department of veterans affairs.--
        The term `qualified travel expenses' does not include any 
        travel expense which is reimbursed by the Department of 
        Veterans Affairs or any other insurance plan.
            ``(3) Limitation.--Travel expenses incurred by a veteran 
        shall not be taken into account under paragraph (1) unless--
                    ``(A) the principal place of abode of the veteran 
                is more than 25 miles from the medical center in which 
                the treatment is provided or examination conducted, and
                    ``(B) such medical center is the nearest medical 
                center of the Department of Veterans Affairs to such 
                place of abode.
            ``(4) Travel expenses.--The term `travel expenses' includes 
        transportation, food, and lodging.
    ``(d) Other Definitions.--For purposes of this section--
            ``(1) Veteran.--The term `veteran' has the meaning given 
        such term by section 101(2) of title 38, United States Code.
            ``(2) Service-connected disability.--The term `service-
        connected disability' has the meaning given such term under 
        section 101(13) of such Code.
            ``(3) Family member.--The members of an individual's family 
        shall be determined under section 4946(d); except that such 
        members also shall include the brothers and sisters (whether by 
        the whole or half blood) of the individual and their 
        spouses.''.
            (2) Deduction allowed whether or not taxpayer itemizes 
        other deductions.--Subsection (a) of section 62 of such Code 
        (defining adjusted gross income) is amended by inserting before 
        the last sentence the following new paragraph:
            ``(22) Travel expenses of veterans for health care at 
        medical centers of the department of veterans affairs.--The 
        deduction allowed by section 224.''.
            (3) Clerical amendments.--The table of sections for part 
        VII of subchapter B of chapter 1 of such Code is amended by 
        striking the item relating to section 224 and inserting the 
        following:

``Sec. 224. Travel expenses of veterans for health care at medical 
                            centers of the Department of Veterans 
                            Affairs.
``Sec. 225. Cross reference.''.
            (4) Effective date.--The amendments made by this section 
        shall apply to taxable years beginning after December 31, 2008.
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