[Congressional Record Volume 140, Number 116 (Wednesday, August 17, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 17, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          AMENDMENTS SUBMITTED

                                 ______


                    THE HEALTH SECURITY ACT OF 1994

                                 ______


                NICKLES (AND OTHERS) AMENDMENT NO. 2563

  Mr. NICKLES (for himself, Mr. Moynihan, Mr. Packwood, Mr. Craig, Mr. 
Coats, Mr. Gregg, Mr. D'Amato, Mr. Grassley, Mr. Daschle, Mr. Stevens, 
Mr. Durenberger, Mr. Shelby, Mr. Mack, Mr. Gorton, Mr. Roth, Mr. Lott, 
Mr. Burns, Mr. Exon, Mr. Murkowski, Mr. Smith, Mr. Thurmond, Mr. 
Specter, Mr. Wofford, and Mr. Coverdell) proposed an amendment to 
amendment No. 2560 proposed by Mr. Mitchell to the bill (S. 2351) to 
achieve universal health insurance coverage, and for other purposes; as 
follows:

       On page 145, strike lines 1 through 5.
                                 ______


                DASCHLE (AND OTHERS) AMENDMENT NO. 2564

  Mr. DASCHLE (for himself, Mr. Harkin, Mr. Rockefeller, Mr. Baucus, 
Mr. Reid, Mr. Leahy, Mr. Wofford, and Mr. Campbell) proposed an 
amendment to amendment No. 2560 proposed by Mr. Mitchell to the bill S. 
2351, supra; as follows:

       On page 112, line 6, insert ``including residents of rural 
     areas'' before the period.
       On page 215, line 10, strike ``(c)'' and insert ``(d)''.
       On page 215, between lines 9 and 10, insert the following 
     new subsection:
       (c) Transfer of Duties.--Effective January 1, 1996, the 
     functions, powers, duties, and authority that were carried 
     out in accordance with Federal law by the Office of Rural 
     Health Policy in the Department of Health and Human Services 
     are transferred to the Office of the Assistant Secretary for 
     Rural Health in the Department of Health and Human Services.
       On page 612, line 24, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 613, line 9, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 647, strike lines 25 and 26, and insert the 
     following:
       ``For purposes of carrying out section 3341, there are 
     authorized to be appropriated $15,000,000 for each of the 
     fiscal years 1997 through 2001.''.
       On page 664, line 10, strike ``or health professional 
     shortage areas'' and insert ``area, health professional 
     shortage area, or other rural underserved area (as designated 
     by the Governor)''.
       On page 651, between lines 9 and 10, add the following new 
     paragraph:
       (3) Subpart f.--For the purpose of providing funds under 
     subpart F, there are authorized to be appropriated 
     $10,000,000 for each of the fiscal years 1996 through 2000.
       On page 652, line 18, strike ``and''.
       On page 652, between lines 18 and 19, insert the following 
     new paragraph:
       ``(7) rural health clinics, except that for-profit rural 
     health clinics shall only be eligible for direct loans and 
     grants under subpart C; and''.
       On page 652, line 19, strike ``(7)'' and insert ``(8)''.
       On page 653, after line 23, add the following new 
     subsection:
       (f) Purposes and Conditions.--Grants shall be made under 
     this part for the purposes and subject to all of the 
     conditions under which eligible entities otherwise receive 
     funding to provide health services to medically underserved 
     populations under the Public Health Service Act. The 
     Secretary shall prescribe comparable purposes and conditions 
     for eligible entities not receiving funding under the Public 
     Health Service Act, including conditions with respect to the 
     availability of services in the area served (as provided for 
     in section 330(e)(3)(A) of such Act), and conformance of fee 
     and payment schedules with prevailing rates (as provided for 
     in section 330(e)(3)(F) of such Act). With respect to 
     federally qualified health centers, such comparable purposes 
     and conditions shall include conditions concerning sliding 
     fee scales under section 1128B(b)(3)(D) of the Social 
     Security Act and waivers of deductibles under section 1833(d) 
     of such Act.
       On page 672, line 1, strike the subsection heading and 
     insert ``Federally qualified health centers and rural health 
     clinics''.
       On page 673, line 3, insert ``and rural health clinics'' 
     after ``Act)''.
       On page 675, between lines 16 and 17, add the following new 
     subpart:

               Subpart F--Rural-Based Managed Care Grants

     SEC. 3467. RURAL-BASED MANAGED CARE GRANTS.

       (a) In General.--The Secretary shall award grants for the 
     development and operation of rural-based managed care 
     networks that integrate the medicare population of the area 
     served.
       (b) Eligible Entities.--To be eligible to receive a grant 
     under subsection (a), an applicant organization shall--
       (1) prepare and submit to the Secretary an application, at 
     such time, in such manner and containing such information as 
     the Secretary may require;
       (2) be based or provide services in rural or rural 
     underserved areas; and
       (3) be currently operating or in the process of 
     establishing a provider network serving the nonmedicare 
     population .
       (c) Use of Funds.--Funds provided under a grant under this 
     section may be used--
       (1) for the development and implementation of rural-based 
     managed care networks;
       (2) for data and information systems, including 
     telecommunications;
       (3) for meeting solvency requirements for a risk-bearing 
     entity under the medicare program under title XVIII of the 
     Social Security Act;
       (4) for the recruitment of health care providers; or
       (5) for enabling services, including transportation and 
     translation.
       (d) Priority.--In awarding grants under subsection (a), the 
     Secretary shall give priority to--
       (1) applicants that will use amounts received under the 
     grant to develop and operate rural-based managed care 
     networks that would serve at least one rural underserved 
     area; and
       (2) applicants that involve local residents and providers 
     in the planning and development of the rural-based managed 
     network.
       (e) Definitions.--As used in this section
       (1) Rural area.--The term ``rural area'' means a rural area 
     as described in section 1886(d)(2)(D) of the Social Security 
     Act.
       (2) Underserved rural area.--The term ``underserved rural 
     area'' means a health professional shortage area under 
     section 332 of the Public Health Service Act (42 U.S.C. 254e) 
     or an area designated as underserved by the Governor of a 
     State taking into account--
       (A) financial and geographic access to health plans by 
     residents of such area; and
       (B) the availability, adequacy, and quality of qualified 
     providers and health care facilities in such area.
       (f) Study.--The Secretary shall study different risk-
     bearing approaches for rural managed care and payment 
     methodologies that differ from or modify the medicare average 
     area per capita cost payment methodology.
       Beginning on page 675, strike line 24 and all that follows 
     through line 4 on page 676, and insert the following: 
     ``priated $314,000,000 for fiscal year 1996, $285,000,000 for 
     fiscal year 1997, $365,000,000 for fiscal year 1998, 
     $382,000,000 for fiscal year 1999, $386,000,000 for fiscal 
     year 2000, $91,500,000 for fiscal year 2001, $53,350,000 for 
     fiscal year 2002, $38,100,000 for fiscal year 2003, and 
     $38,100,000 for fiscal year 2004, of which $2,000,000 shall 
     be made available in each of the fiscal years 1996 through 
     2000 to carry out section 338L of the Public Health Service 
     Act.''.
       On page 676, line 10, strike ``NURSES'' and insert 
     ``ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS''.
       On page 676, line 20, strike ``nurse anesthetists'' and 
     insert ``nurse anesthetists or physician assistants''.
       On page 676, lines 21 and 22, strike ``nurse anesthetists'' 
     and insert ``nurse anesthetists or physician assistants''.
       On page 677, between lines 13 and 14, add the following new 
     parts:

       PART 4--ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS

     SEC. 3491. ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS.

       (a) In General.--The Attorney General, in consultation with 
     the Commissioner of the Federal Trade Commission, shall 
     clarify existing and future policy guidelines, with respect 
     to safe harbors, by providing additional illustrative 
     examples with respect to the conduct of activities relating 
     to the provision of health care services in rural areas.
       (b) Dissemination of Information.--The Attorney General, in 
     consultation with the Commissioner of the Federal Trade 
     Commission and the Assistant Secretary for Rural Health, 
     shall develop methods for the dissemination of the guidelines 
     established under subsection (a) to rural health care 
     providers.

                   PART 5--EMERGENCY MEDICAL SYSTEMS

     SEC. 3495. GRANTS TO STATES REGARDING AIRCRAFT FOR 
                   TRANSPORTING RURAL VICTIMS OF MEDICAL 
                   EMERGENCIES.

       Part E of title XII of the Public Health Service Act (42 
     U.S.C. 300d-51 et seq.) is amended by adding at the end 
     thereof the following new section:

     ``SEC. 1252. GRANTS FOR SYSTEMS TO TRANSPORT RURAL VICTIMS OF 
                   MEDICAL EMERGENCIES.

       ``(a) In General.--The Secretary shall make grants to 
     States to assist such States in the creation or enhancement 
     of air medical transport systems that provide victims of 
     medical emergencies in rural areas with access to treatments 
     for the injuries or other conditions resulting from such 
     emergencies.
       ``(b) Application and Plan.--
       ``(1) Application.--To be eligible to receive a grant under 
     subsection (a), a State shall prepare and submit to the 
     Secretary an application in such form, made in such manner, 
     and containing such agreements, assurances, and information, 
     including a State plan as required in paragraph (2), as the 
     Secretary determines to be necessary to carry out this 
     section.
       ``(2) State plan.--An application submitted under paragraph 
     (1) shall contain a State plan that shall--
       ``(A) describe the intended uses of the grant proceeds and 
     the geographic areas to be served;
       ``(B) demonstrate that the geographic areas to be served, 
     as described under subparagraph (A), are rural in nature;
       ``(C) demonstrate that there is a lack of facilities 
     available and equipped to deliver advanced levels of medical 
     care in the geographic areas to be served;
       ``(D) demonstrate that in utilizing the grant proceeds for 
     the establishment or enhancement of air medical services the 
     State would be making a cost-effective improvement to 
     existing ground-based or air emergency medical service 
     systems;
       ``(E) demonstrate that the State will not utilize the grant 
     proceeds to duplicate the capabilities of existing air 
     medical systems that are effectively meeting the emergency 
     medical needs of the populations they serve;
       ``(F) demonstrate that in utilizing the grant proceeds the 
     State is likely to achieve a reduction in the morbidity and 
     mortality rates of the areas to be served, as determined by 
     the Secretary;
       ``(G) demonstrate that the State, in utilizing the grant 
     proceeds, will--
       ``(i) maintain the expenditures of the State for air and 
     ground medical transport systems at a level equal to not less 
     than the level of such expenditures maintained by the State 
     for the fiscal year preceding the fiscal year for which the 
     grant is received; and
       ``(ii) ensure that recipients of direct financial 
     assistance from the State under such grant will maintain 
     expenditures of such recipients for such systems at a level 
     at least equal to the level of such expenditures maintained 
     by such recipients for the fiscal year preceding the fiscal 
     year for which the financial assistance is received;
       ``(H) demonstrate that persons experienced in the field of 
     air medical service delivery were consulted in the 
     preparation of the State plan; and
       ``(I) contain such other information as the Secretary may 
     determine appropriate.
       ``(c) Considerations in Awarding Grants.--In determining 
     whether to award a grant to a State under this section, the 
     Secretary shall--
       ``(1) consider the rural nature of the areas to be served 
     with the grant proceeds and the services to be provided with 
     such proceeds, as identified in the State plan submitted 
     under subsection (b); and
       ``(2) give preference to States with State plans that 
     demonstrate an effective integration of the proposed air 
     medical transport systems into a comprehensive network or 
     plan for regional or statewide emergency medical service 
     delivery.
       ``(d) State Administration and Use of Grant.--
       ``(1) In general.--The Secretary may not make a grant to a 
     State under subsection (a) unless the State agrees that such 
     grant will be administered by the State agency with principal 
     responsibility for carrying out programs regarding the 
     provision of medical services to victims of medical 
     emergencies or trauma.
       ``(2) Permitted uses.--A State may use amounts received 
     under a grant awarded under this section to award subgrants 
     to public and private entities operating within the State.
       ``(3) Opportunity for public comment.--The Secretary may 
     not make a grant to a State under subsection (a) unless that 
     State agrees that, in developing and carrying out the State 
     plan under subsection (b)(2), the State will provide public 
     notice with respect to the plan (including any revisions 
     thereto) and facilitate comments from interested persons.
       ``(e) Number of Grants.--The Secretary shall award grants 
     under this section to not less than 7 States.
       ``(f) Reports.--
       ``(1) Requirement.--A State that receives a grant under 
     this section shall annually (during each year in which the 
     grant proceeds are used) prepare and submit to the Secretary 
     a report that shall contain--
       ``(A) a description of the manner in which the grant 
     proceeds were utilized;
       ``(B) a description of the effectiveness of the air medical 
     transport programs assisted with grant proceeds; and
       ``(C) such other information as the Secretary may require.
       ``(2) Termination of fundings.--In reviewing reports 
     submitted under paragraph (1), if the Secretary determines 
     that a State is not using amounts provided under a grant 
     awarded under this section in accordance with the State plan 
     submitted by the State under subsection (b), the Secretary 
     may terminate the payment of amounts under such grant to the 
     State until such time as the Secretary determines that the 
     State comes into compliance with such plan.
       ``(g) Definition.--As used in this section, the term `rural 
     areas' means geographic areas that are located outside of 
     standard metropolitan statistical areas, as identified by the 
     Secretary.
       ``(h) Authorization of Appropriations.--There are 
     authorized to be appropriated to make grants under this 
     section, $15,000,000 for fiscal year 1995, and such sums as 
     may be necessary for each for fiscal years 1996 and 1997.''.
       Beginning on page 718, strike line 23 and all that follows 
     through line 5 on page 719, and insert the following new 
     paragraph:
       ``(8) with respect to the National Health Service Corps 
     program referred to in section 3471, $314,000,000 for fiscal 
     year 1996, $285,000,000 for fiscal year 1997, $365,000,000 
     for fiscal year 1998, $382,000,000 for fiscal year 1999, 
     $386,000,000 for fiscal year 2000, $91,500,000 for fiscal 
     year 2001, $53,350,000 for fiscal year 2002, $38,100,000 for 
     fiscal year 2003, and $38,100,000 for fiscal year 2004, of 
     which $2,000,000 shall be made available in each of the 
     fiscal years 1996 through 2000 to carry out section 338L of 
     the Public Health Service Act;''.
       On page 720, line 22, strike ``; and'' and insert a 
     semicolon.
       On page 720, between lines 22 and 23, insert the following 
     new paragraph:
       ``(14) with respect to the development of rural 
     telemedicine under section 3341, $15,000,000 for each of the 
     fiscal years 1997 through 2001; and''.
       On page 720, line 23, strike ``(14)'' and insert ``(15)''.
       On page 725, strike lines 7 through 11, and insert the 
     following:
       ``(6) in subsection (l), by striking paragraph (1) and 
     inserting the following new paragraph:
       `` `(1) In general.--The Secretary shall use amounts made 
     available under section 3471 of the Health Security Act to 
     carry out this section in each of the fiscal years 1996 
     through 2000.' ''.
       On page 777, line 18, strike ``and medical assistance 
     facilities''.
       On page 780, line 3, insert ``In the case of payment under 
     this subsection to medical assistance facilities, the lesser-
     of-cost-or charges provisions under subsection (j) are not 
     applicable.'' after ``services.''.
       Beginning on page 808, strike line 16 and all that follows 
     through page 809, line 4, and insert the following:
       (2) by inserting ``described in paragraph (2) and services 
     furnished by a physician assistant, nurse practitioner, or a 
     clinical nurse specialist described in such paragraph that 
     would by physicians' services if furnished by a physician'' 
     after ``physicians' services'',
       (3) by inserting ``physician assistant, nurse practitioner, 
     or a clinical nurse specialist'' after ``physician'',
       (4) by striking ``10 percent'' and inserting ``the 
     applicable percent'', and
       (5) by adding at the end the following new paragraph:
       ``(2)(A) The applicable percent referred to in paragraph 
     (1) is--
       ``(i) in the case of physicians' services that are primary 
     care services, a percent determined by the Secretary that may 
     not be less than 10 percent and may not exceed 20 percent,
       ``(ii) in the case of services furnished by a physician 
     assistant, nurse practitioner, or a clinical nurse specialist 
     described in such paragraph that would be physicians' 
     services that are primary care services if a physician 
     furnished the services, a percent to be determined by the 
     Secretary that is equal to the percent determined in clause 
     (i) and determined so that the total amount of such payments 
     under this clause and clause (i) is equal to the amount that 
     would have been paid under clause (i) if the applicable 
     percent for such clause was equal to 20 percent, and
       ``(iii) in the case of physicians' services other than 
     primary care services furnished in a health professional 
     shortage area located in a rural area (as defined in section 
     1886(d)(2)(D)), 10 percent.
       On page 873, line 20, insert ``urban and rural'' after 
     ``representative of the''.
       On page 874, line 1, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 874, line 4, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 1390, line 22, insert ``and that at least one 
     member of the Commission is a resident of a rural area'' 
     before the period at the end.

                                 ______


                   GRASSLEY AMENDMENTS NOS. 2565-2567

  (Ordered to lie on the table.)
  Mr. GRASSLEY submitted three amendments intended to be proposed by 
him to amendment No. 2560 proposed by Mr. Mitchell to the bill S. 2351, 
supra; as follows:

                           Amendment No. 2565

       On page 263, between lines 15 and 16, insert the following 
     new section:

     SEC.  . LIMITATION ON FULL-TIME EQUIVALENT POSITIONS.

       Nothing in this Act, or an amendment made by this Act, 
     shall be construed as permitting the total number of full-
     time equivalent positions in all agencies to exceed the 
     limitations contained in section 5 of the Federal Workforce 
     Restructuring Act of 1994.
                                  ____


                           Amendment No. 2566

       On page 817, strike lines 14 through 24, and insert the 
     following:
       (a) Coverage in Outpatient Settings; direct Payments to 
     Nurse Practitioners.--
       (1) In general.--Section 1861(s)(2)(K) (42 U.S.C. 
     1395x(s)(2))K)) is amended--
       (A) in clause (i)--
       (i) by striking ``or'' at the end of subclause (II); and
       (ii) by inserting ``or (IV) in an outpatient setting as 
     defined by the Secretary'' following ``shortage area,''; and
       (B) in clause (ii)--
       (i) by striking ``in a skilled'' and inserting ``in (I) a 
     skilled''; and
       (ii) by inserting ``, or (II) in an outpatient setting (as 
     defined by the Secretary),'' after ``(as defined in section 
     1919(a))''.
       (2) Direct payments to nurse practitioners in outpatient 
     settings.--(A) Section 1833(r)(1) (42 U.S.C. 1395l(r)(1)) is 
     amended by inserting ``or for services described in section 
     1861(s)(2)(K)(ii)(II) (relating to nurse practitioner 
     services in outpatient settings),'' after ``rural area),''.
       (B) Section 1842(b)(6)(C) (42 U.S.C. 1395u(b)(6)(C)) is 
     amended by striking ``clauses (i), (ii), or (iv)'' and 
     inserting ``clauses (i), (ii)(I), or (iv)''.
       On page 820, line 4, strike ``(a)(2)'' and insert 
     ``(a)(1)(B)''.
                                  ____


                           Amendment No. 2567

       On page 1226, beginning with line 4, strike all through 
     page 1227, line 13.
       On page 1227, line 14, strike ``(B)'' and insert ``(A)''.
       On page 1227, line 19, strike ``(C)'' and insert ``(B)''.

  Mr. GRASSLEY. Mr. President, I want to speak and have it placed in 
the proper place in the Record so it does not interfere with the debate 
on rural health care a discussion of three amendments that I am going 
to offer later on in this bill's debate, and I want to send those 
amendments to the desk for file.
  I am going to offer these amendments at such time as the managers of 
the bill see fit. In the meantime I want to have them on record so 
people will know what I am thinking about doing. I do not want to play 
any games with anybody. There is no reason to keep these amendments 
secret.
  One of the amendments deals with one of the subject matters that is 
going to be involved with the Daschle amendment anyway.
  The first amendment would ensure that the effects of the Mitchell 
bill would not supersede the provisions of another law that was passed 
earlier this year, Public Law 103-226. That law established ceilings 
for the numbers of Federal workers over the next 6 years.
  Based on an amendment that Senator Phil Gramm and I offered, the 
ceilings are set forth in the Federal Workforce Restructuring Act of 
1994. Section 5 of the act is entitled ``Reduction of Federal Full-Time 
Equivalent Positions.'' The ceilings are set for fiscal year 1994 
through fiscal year 1999.
  The purpose of the amendment originally offered by Senator Gramm and 
myself was to put teeth in the administration's program to reinvent 
government. I am a strong believer in the reinventing Government 
program. I support the efforts of the Vice President and have indicated 
that many times here on the floor.
  The Congress is also on record strongly supporting the program, 
because the Senate voted 82 to 14 in support of the Gramm-Grassley 
amendment.
  The amendment that I intend to offer to the Mitchell bill would 
preserve what Congress did earlier this year. It would say that the 
Mitchell bill would have to be consistent with section 5 of Public Law 
103-226. In other words, the Mitchell bill could not add to the overall 
full-time equivalents, or what we call FTE's, established in law.
  This amendment is relevant, I believe. The short answer of why is 
that is there is a great fear on our side of the aisle that the 
Mitchell bill would lead to a new, flourishing bureaucracies, and even 
though the author denies this. So my amendment is a way to keep the 
author of the legislation consistent with what this Senate previously 
had done, not to increase the number of employees. If there is not 
going to be bureaucracies, there will not be bureaucracies. I want to 
make it clear that my intention is not to call into question the 
author's assertion. Rather, my intention is to ensure that the 
statutory ceilings are protected.

  As our side has analyzed the Mitchell bill, it would create 50 new 
Federal bureaucracies. They would include, among others, a National 
Health Benefit Board and a National Health Care Cost and Coverage 
Commission. It would also give hundreds of new powers to the Secretary 
of HHS as well as the Secretary of Labor.
  The point is that, if you have new bureaucracies, then new 
bureaucrats would have to do this new work. Presumably, they could be 
shifted from elsewhere within the Federal work force. Such a zero-sum 
shift would be acceptable from the standpoint of protection of the 
limits of employment under current law as long as the overall totals 
established in the law are not breached.
  However, when I say acceptable, I want to make it clear I am talking 
about from the standpoint of protecting current law. I am not accepting 
the motion that all these bureaucracies are either wise or needed.
  The second amendment that I am filling is also a portion of the 
amendment that is before this body. It deals with the direct Medicare 
reimbursement to nurse practitioners providing services in outpatient 
settings. I first introduced this legislation in November 1991. I was 
successful in adding this legislation to the Senate version of H.R. 11 
in 1992, which was eventually vetoed by President Bush.
  I offered this amendment again in the Senate Finance Committee's 
version of OBRA fiscal year 1993. And I was successful in adding this 
legislation to the Finance Committee's health reform bill. Senator 
Mitchell has included this legislation in his bill. But it appears that 
some drafting errors make it necessary to refine it. I think that is 
what Senator Daschle is trying to accomplish, because it would not in 
original bill permit direct reimbursement of these providers. The 
amendment I file separately would also deal with that issue.
  Finally, Mr. President, my third amendment that I want to present to 
the Senate for consideration over the next few days would do two 
things: It would strike what is a de facto employer mandate on the 
self-employed as well as the resulting tax penalty for noncompliance. 
This is in section 7203 of the Mitchell bill.
  Mr. President, I want to make sure my colleagues are made aware of my 
intentions to offer these amendments to the Mitchell bill, and I would 
urge their cooperation and support.
  As I indicated, Mr. President, I want these amendments placed or 
filed or sent to the desk merely for printing in the Record and for 
everybody's consideration over the next few days.

                          ____________________