[Congressional Record Volume 140, Number 136 (Monday, September 26, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: September 26, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                         ADDITIONAL STATEMENTS

                                 ______


             THE HEALTH INNOVATION PARTNERSHIP ACT OF 1994

 Mr. GRAHAM. Mr. President, on September 22, 1994, I introduced 
S. 2452, the Health Innovation Partnership Act of 1994. My floor 
statement, a summary of the bill, and various articles on State 
innovation were included in the Record. I would ask that the bill be 
printed in its entirety in today's Record.
  The text of the bill follows:

                                S. 2452

       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 ``Health Innovation 
     Partnership Act of 1994''.

     SEC. 2. FINDINGS.

       The Congress finds the following:
       (1) Americans support universal coverage. The people of 
     this country agree that all Americans, rich and poor, should 
     be guaranteed access to affordable, high-quality health care.
       (2) Although there is common agreement on the goal of 
     universal coverage, there are many different ways to achieve 
     this goal. The States can play an important role in achieving 
     universal coverage for our population, demonstrating 
     additional health reforms that may be needed on a national 
     level to enhance access to affordable, high-quality health 
     care. The States can also serve as testing grounds to 
     identify effective alternatives for making the transition to 
     universal coverage, while maintaining the strengths of the 
     current health care system.
       (3) Maintaining the high quality of health care Americans 
     expect and controlling costs are also important goals of 
     health care reform. As payers of health care, the States have 
     a strong incentive to ensure that such States purchase high-
     quality, cost-effective services for the residents of such 
     States. The States can develop and test alternative payment 
     and delivery systems to ensure that these goals are achieved.
       (4) There are many health-related issues that should be 
     addressed at the State level before their implementation on 
     the national level. As with social security and child labor 
     protections, States can lead the way in testing ideas for 
     national application.
       (5) The States should have the flexibility to test 
     alternative health reforms with the objectives of increasing 
     access to care, controlling health care costs, and 
     maintaining or improving the quality of health care.
                    TITLE I--HEALTH INSURANCE REFORM

     SEC. 1001. ESTABLISHMENT OF STANDARDS.

       (a) In General.--The Secretary of Health and Human Services 
     (hereafter referred to in this section as the ``Secretary'') 
     shall request that the National Association of Insurance 
     Commissioners (hereafter referred to in this section as the 
     ``Association'') develop, not later than 6 months after the 
     date of enactment of this Act, standards for health insurance 
     plans with respect to--
       (1) the renewability of coverage under such plans;
       (2) the portability of coverage under such plans, 
     including--
       (A) limitations on the use of pre-existing conditions;
       (B) the concept of an ``amnesty period'' during which 
     limitations on pre-existing conditions would be suspended; 
     and
       (C) the advisability of open enrollment periods;
       (3) guaranteed issue with respect to all health insurance 
     coverage products;
       (4) the establishment of an adjusted community rating 
     system with adjustment factors limited to age (with no more 
     than a 2:1 variation in premiums based on age) and geography;
       (5) solvency standards for health insurance plans 
     regulations under Federal and State law, including the 
     development of risk-based capital standards for health plans, 
     solvency standards for health plans, self-funded employer-
     sponsored health plans, and multi-employer welfare 
     arrangements and association plans;
       (6) stop-loss standards for self-funded health insurance 
     plans and multi-employer welfare arrangements and association 
     plans;
       (7) the identification of minimum employer size for self-
     funding and the interrelationship between self-funding and 
     the community-rated pool of enrollees; and
       (8) any other areas determined appropriate by the 
     Secretary.
       (b) Review.--Not later than 30 days after receipt of the 
     standards developed by the Association under subsection (a), 
     the Secretary shall complete a review of such standards. If 
     the Secretary, based on such review, approves such standards, 
     such standards shall apply with respect to all health 
     insurance plans offered or operating in a State on and after 
     the date specified in subsection (d) herein.
       (c) Failure To Develop Standards or Failure To Approve.--If 
     the Association fails to develop standards within the 6-month 
     period referred to in subsection (a), or the Secretary fails 
     to approve any standards developed under such subsection, the 
     Secretary shall develop, not later than 15 months after the 
     date of enactment of this Act, standards applicable to health 
     insurance plans, including standards related to the matter 
     described in paragraphs (1) through (7) of subsection (a) 
     (``Federal standards'') and such standards shall apply with 
     respect to all health insurance plans offered or operating in 
     a State on and after the date specified in subsection (d) 
     herein.
       (d)(1) Subject to clause (2), the date specified in this 
     subparagraph for a State is the date the State adopts the 
     NAIC standards or the Federal standards or 1 year after the 
     date the Association or the Secretary first adopts such 
     standards, whichever is earlier.
       (2) In the case of a State which the Secretary identifies, 
     in consultation with the Association, as--
       (A) requiring State legislation (other than legislation 
     appropriating funds) in order for health insurance policies 
     to meet the NAIC or Federal standards, but
       (B) having a legislature which is not scheduled to meet in 
     1992 in a legislative session in which such legislation may 
     be considered, the date specified in this subparagraph is the 
     first day of the first calendar quarter beginning after the 
     close of the first legislative session of the State 
     legislature that begins on or after January 1, 1992. For 
     purposes of the previous sentence, in the case of a State 
     that has a 2-year legislative session, each year of such 
     session shall be deemed to be a separate regular session of 
     the State legislature.
       (e) In promulgating standards under this paragraph, the 
     Association or Secretary shall consult with a working group 
     composed or representatives of issuers of health insurance 
     policies, consumer groups, health insurance beneficiaries, 
     and other qualified individuals. Such representatives shall 
     be selected in a manner so as to assure balanced 
     representation among the interested groups.
       (f) Effect on State Law.--Nothing in this section shall be 
     construed to preempt any State law to the extent that such 
     State law implements more progressive reforms than those 
     implemented under the standards developed under this section, 
     as determined by the Secretary.

     SEC. 1002. MEDICARE SELECT.

       (a) Amendments to Provisions Relating to Medicare Select 
     Policies.--
       (1) Permitting medicare select policies in all states.--
     Subsection (c) of section 4358 of the Omnibus Budget 
     Reconciliation Act of 1990 is hereby repealed.
       (2) Requirements of medicare select policies.--Section 
     1882(t)(1) (42 U.S.C. 1395ss(t)(1)) is amended to read as 
     follows:
       ``(1)(A) If a medicare supplemental policy meets the 
     requirements of the 1991 NAIC Model Regulation or 1991 
     Federal Regulation and otherwise complies with the 
     requirements of this section except that--
       ``(i) the benefits under such policy are restricted to 
     items and services furnished by certain entities (or reduced 
     benefits are provided when items or services are furnished by 
     other entities), and
       ``(ii) in the case of a policy described in subparagraph 
     (C)(i)--
       ``(I) the benefits under such policy are not one of the 
     groups or packages of benefits described in subsection 
     (p)(2)(A),
       ``(II) except for nominal copayments imposed for services 
     covered under part B of this title, such benefits include at 
     least the core group of basic benefits described in 
     subsection (p)(2)(B), and
       ``(III) an enrollee's liability under such policy for 
     physician's services covered under part B of this title is 
     limited to the nominal copayments described in subclause 
     (II),

     the policy shall nevertheless be treated as meeting those 
     requirements if the policy meets the requirements of 
     subparagraph (B).
       ``(B) A policy meets the requirements of this subparagraph 
     if--
       ``(i) full benefits are provided for items and services 
     furnished through a network of entities which have entered 
     into contracts or agreements with the issuer of the policy,
       ``(ii) full benefits are provided for items and services 
     furnished by other entities if the services are medically 
     necessary and immediately required because of an unforeseen 
     illness, injury, or condition and it is not reasonable given 
     the circumstances to obtain the services through the network,
       ``(iii) the network offers sufficient access,
       ``(iv) the issuer of the policy has arrangements for an 
     ongoing quality assurance program for items and services 
     furnished through the network,
       ``(v)(I) the issuer of the policy provides to each enrollee 
     at the time of enrollment an explanation of--
       ``(aa) the restrictions on payment under the policy for 
     services furnished other than by or through the network,
       ``(bb) out of area coverage under the policy,
       ``(cc) the policy's coverage of emergency services and 
     urgently needed care, and
       ``(dd) the availability of a policy through the entity that 
     meets the 1991 Model NAIC Regulation or 1991 Federal 
     Regulation without regard to this subsection and the premium 
     charged for such policy, and
       ``(II) each enrollee prior to enrollment acknowledges 
     receipt of the explanation provided under subclause (I), and
       ``(vi) the issuer of the policy makes available to 
     individuals, in addition to the policy described in this 
     subsection, any policy (otherwise offered by the issuer to 
     individuals in the State) that meets the 1991 Model NAIC 
     Regulation or 1991 Federal Regulation and other requirements 
     of this section without regard to this subsection.
       ``(C)(i) A policy described in this subparagraph--
       ``(I) is offered by an eligible organization (as defined in 
     section 1876(b)),
       ``(II) is not a policy or plan providing benefits pursuant 
     to a contract under section 1876 or an approved demonstration 
     project described in section 603(c) of the Social Security 
     Amendments of 1983, section 2355 of the Deficit Reduction Act 
     of 1984, or section 9412(b) of the Omnibus Budget 
     Reconciliation Act of 1986, and
       ``(III) provides benefits which, when combined with 
     benefits which are available under this title, are 
     substantially similar to benefits under policies offered to 
     individuals who are not entitled to benefits under this 
     title.
       ``(ii) In making a determination under subclause (III) of 
     clause (i) as to whether certain benefits are substantially 
     similar, there shall not be taken into account, except in the 
     case of preventive services, benefits provided under policies 
     offered to individuals who are not entitled to benefits under 
     this title which are in addition to the benefits covered by 
     this title and which are benefits an entity must provide in 
     order to meet the definition of an eligible organization 
     under section 1876(b)(1).''.
       (b) Renewability of Medicare Select Policies.--Section 
     1882(q)(1) (42 U.S.C. 1395ss(q)(1)) is amended--
       (1) by striking ``(1) Each'' and inserting ``(1)(A) Except 
     as provided in subparagraph (B), each'';
       (2) by redesignating subparagraphs (A) and (B) as clauses 
     (i) and (ii), respectively; and
       (3) by adding at the end the following new subparagraph:
       ``(B)(i) In the case of a policy that meets the 
     requirements of subsection (t), an issuer may cancel or 
     nonrenew such policy with respect to an individual who leaves 
     the service area of such policy; except that, if such 
     individual moves to a geographic area where such issuer, or 
     where an affiliate of such issuer, is issuing medicare 
     supplemental policies, such individual must be permitted to 
     enroll in any medicare supplemental policy offered by such 
     issuer or affiliate that provides benefits comparable to or 
     less than the benefits provided in the policy being canceled 
     or nonrenewed. An individual whose coverage is canceled or 
     nonrenewed under this subparagraph shall, as part of the 
     notice of termination or nonrenewal, be notified of the right 
     to enroll in other medicare supplemental policies offered by 
     the issuer or its affiliates.
       ``(ii) For purposes of this subparagraph, the term 
     `affiliate' shall have the meaning given such term by the 
     1991 NAIC Model Regulation.''.
       (c) Civil Penalty.--Section 1882(t)(2) (42 U.S.C. 
     1395ss(t)(2)) is amended--
       (1) by striking ``(2)'' and inserting ``(2)(A)'';
       (2) by redesignating subparagraphs (A), (B), (C), and (D) 
     as clauses (i), (ii), (iii), and (iv), respectively;
       (3) in clause (iv), as redesignated--
       (A) by striking ``paragraph (1)(E)(i)'' and inserting 
     ``paragraph (1)(B)(v)(I); and
       (B) by striking ``paragraph (1)(E)(ii)'' and inserting 
     ``paragraph (1)(B)(v)(II)'';
       (4) by striking ``the previous sentence'' and inserting 
     ``this subparagraph''; and
       (5) by adding at the end the following new subparagraph:
       ``(B) If the Secretary determines that an issuer of a 
     policy approved under paragraph (1) has made a 
     misrepresentation to the Secretary or has provided the 
     Secretary with false information regarding such policy, the 
     issuer is subject to a civil money penalty in an amount not 
     to exceed $100,000 for each such determination. The 
     provisions of section 1128A (other than the first sentence of 
     subsection (a) and other than subsection (b)) shall apply to 
     a civil money penalty under this subparagraph in the same 
     manner as such provisions apply to a penalty or proceeding 
     under section 1128A(a).''.
       (d) Effective Dates.--
       (1) NAIC standards.--If, within 9 months after the date of 
     the enactment of this Act, the National Association of 
     Insurance Commissioners (hereafter in this subsection 
     referred to as the ``NAIC'') makes changes in the 1991 NAIC 
     Model Regulation (as defined in section 1882(p)(1)(A) of the 
     Social Security Act) to incorporate the additional 
     requirements imposed by the amendments made by this section, 
     section 1882(g)(2)(A) of such Act shall be applied in each 
     State, effective for policies issued to policyholders on and 
     after the date specified in paragraph (3), as if the 
     reference to the Model Regulation adopted on June 6, 1979, 
     were a reference to the 1991 NAIC Model Regulation (as so 
     defined) as changed under this paragraph (such changed 
     Regulation referred to in this subsection as the ``1995 NAIC 
     Model Regulation'').
       (2) Secretary standards.--If the NAIC does not make changes 
     in the 1991 NAIC Model Regulation (as so defined) within the 
     9-month period specified in paragraph (1), the Secretary of 
     Health and Human Services (hereafter in this subsection 
     referred to as the ``Secretary'') shall promulgate a 
     regulation and section 1882(g)(2)(A) of the Social Security 
     Act shall be applied in each State, effective for policies 
     issued to policyholders on and after the date specified in 
     paragraph (3), as if the reference to the Model Regulation 
     adopted on June 6, 1979, were a reference to the 1991 NAIC 
     Model Regulation (as so defined) as changed by the Secretary 
     under this paragraph (such changed Regulation referred to in 
     this subsection as the ``1995 Federal Regulation'').
       (3) Date specified.--
       (A) In general.--Subject to subparagraph (B), the date 
     specified in this paragraph for a State is the earlier of--
       (i) the date the State adopts the 1995 NAIC Model 
     Regulation or the 1995 Federal Regulation, or
       (ii) 1 year after the date the NAIC or the Secretary first 
     adopts such regulations.
       (B) Additional legislative action required.--In the case of 
     a State which the Secretary identifies, in consultation with 
     the NAIC, as--
       (i) requiring State legislation (other than legislation 
     appropriating funds) in order for medicare supplemental 
     policies to meet the 1995 NAIC Model Regulation or the 1995 
     Federal Regulation, but
       (ii) having a legislature which is not scheduled to meet in 
     1995 in a legislative session in which such legislation may 
     be considered,

     the date specified in this paragraph is the first day of the 
     first calendar quarter beginning after the close of the first 
     legislative session of the State legislature that begins on 
     or after January 1, 1996. For purposes of the previous 
     sentence, in the case of a State that has a 2-year 
     legislative session, each year of such session shall be 
     deemed to be a separate regular session of the State 
     legislature.
                       TITLE II--STATE INNOVATION
                   Subtitle A--State Waiver Authority

     SEC. 2001. STATE HEALTH REFORM PROJECTS.

       (a) Objectives.--The objectives of the waiver programs 
     approved under this section shall include, but not be limited 
     to--
       (1) achieving the goals of increased health coverage and 
     access;
       (2) containing the annual rate of growth in public and 
     private health care expenditures;
       (3) ensuring that patients receive high-quality, 
     appropriate health care; and
       (4) testing alternative reforms, such as building on the 
     private health insurance system or creating new systems, to 
     achieve the objectives of this Act.
       (b) State Health Reform Applications.--
       (1) In general.--A State may apply for--
       (A) an alternative State health program waiver under 
     paragraph (2); or
       (B) a limited State health care waiver under paragraph (3).
       (2) Alternative state health program waivers.--
       (A) In general.--In accordance with this paragraph, each 
     State desiring to implement an alternative State health 
     program may submit an application for waiver to the Secretary 
     for approval.
       (B) Waiver requirements specified.--A State that desires to 
     receive a program waiver under this paragraph shall prepare 
     and submit to the Secretary, as part of the application, a 
     State health care plan that shall--
       (i) provide and describe the manner in which the State will 
     ensure that individuals residing within the State have 
     expanded access to health care coverage;
       (ii) describe the number and percentage of current 
     uninsured individuals who will achieve coverage under the 
     alternative State health program;
       (iii) describe the benefits package that will be provided 
     to all classes of beneficiaries under the alternative State 
     health program;
       (iv) identify Federal, State, or local programs that 
     currently provide health care services in the State and 
     describe how such programs could be incorporated into or 
     coordinated with the alternative State health program, to the 
     extent practicable;
       (v) provide that the State will develop and implement 
     health care cost containment procedures;
       (vi) describe the public and private sector financing to be 
     provided for the alternative State health program;
       (vii) estimate the amount of Federal, State, and local 
     expenditures, as well as, the costs to business and 
     individuals under the alternative State health program;
       (viii) describe how the State plan will ensure the 
     financial solvency of the alternative State health program;
       (ix) describe any changes in eligibility for public 
     subsidies;
       (x) provide assurances that Federal expenditures under the 
     alternative State health program shall not exceed the Federal 
     expenditures which would otherwise be made in the aggregate 
     for the entire program period;
       (xi) provide quality control assurances and agreements as 
     required by the Secretary;
       (xii) provide for the development and implementation of a 
     State health care delivery system that provides increased 
     access to care in areas of the State where there is an 
     inadequate supply of health care providers;
       (xiii) identify all Federal law waivers required to 
     implement the alternative State health program, including 
     such waivers necessary to achieve the access, cost 
     containment, and quality goals of this Act and the 
     alternative State health program; and
       (xiv) provide that the State will prepare and submit the 
     Secretary such reports as the Secretary may require to carry 
     out program evaluations.
       (C) Project waivers.--
       (i) Criteria for selection.--In selecting from among the 
     applications for alternative State health program waivers, 
     the Secretary shall be satisfied that each approved State 
     alternative State health program--

       (I) will not have a negative effect on quality of care;
       (II) increase coverage of or access for the State's 
     population; and
       (III) will--

       (aa) provide quality of care and premium comparisons 
     directly to employers and individuals in an easy-to-use 
     format,
       (bb) contract with an external peer review organization to 
     monitor the quality of health care plans, and
       (cc) establish a mechanism within the State's grievance 
     process that allows members of a health plan to disenroll at 
     any time if it can be shown that such members were provided 
     erroneous information that biased their health plan 
     selection.
       (ii) Waiver approval.--The Secretary shall approve 
     applications submitted by States that meet the access, cost 
     containment, and quality goals established in this Act and 
     shall waive to the extent necessary to conduct each 
     alternative State health program any of the requirements of 
     this Act, including, but not limited to, eligibility 
     requirements; alternative data collection systems and 
     sampling designs that focus on measuring health status, 
     patient treatment outcomes, and patient satisfaction with 
     health plans, rather than on the collection of 100 percent of 
     patient encounters; and benefit designs; and any provisions 
     of Federal law contained in the following:

       (I) Titles V, XVIII, XIX, and XX of the Social Security 
     Act.
       (II) The Public Health Service Act.
       (III) Any other Federal law authorizing a Federal health 
     care program that the Secretary identifies as providing 
     health care services to qualified recipients.

       (3) Limited state health care waivers.--Each State which 
     does not receive an approved application under paragraph (2) 
     may apply for a limited State health care waiver. The 
     Secretary shall award limited State health care waivers to 
     ensure State demonstrations of health reforms that could 
     address, but are not limited to addressing, the following 
     issues that are likely to provide guidance for the 
     development of additional national health reforms:
       (A) Integration of acute and long-term care systems, 
     including delivery and financing systems.
       (B) Establishment of methodologies that limit expenditures 
     or establish global budgets, including rate setting and 
     provider reimbursements.
       (C) Implementation of a quality management and improvement 
     system.
       (D) Strategies to improve the proper speciality and 
     geographic distribution of the health care work force.
       (E) Initiatives to improve the population's health status.
       (F) Development of uniform health data sets that emphasize 
     the measurement of patient satisfaction, treatment outcomes, 
     and health status.
       (G) Methods for coordinating or integrating State-funded 
     programs that provide services for low-income individuals, 
     including programs authorized by this Act.
       (H) Programs to improve public health.
       (I) Reforms intended to reduce health care fraud and abuse.
       (J) Reforms to reduce the incidence of defensive medicine 
     and practitioner liability costs associated with medical 
     malpractice.
       (K) Development of a uniform billing system.
       (c) Additional Rules Regarding Applications.--
       (1) Technical assistance.--The Secretary shall, if 
     requested, provide technical assistance to States to assist 
     such States in developing waiver applications under this 
     section.
       (2) Initial review.--The Secretary shall complete an 
     initial review of each State application for a waiver under 
     paragraph (2) or (3) of subsection (b) within 40 days of the 
     receipt of such application, analyze the scope of the 
     proposal, and determine whether additional information is 
     needed from the State. The Secretary shall issue a 
     preliminary opinion concerning the likelihood that the 
     application will be approved within such 40-day period and 
     shall advise the State within such period of the need to 
     submit additional information.
       (3) Final decision.--The Secretary shall, within 90 days of 
     the later of--
       (A) the receipt of a State application for a waiver under 
     paragraph (2) or (3) of subsection (b), or
       (B) the date on which the Secretary receives additional 
     information requested from a State under paragraph (1),
     issue a final decision concerning such application.
       (4) Waiver period.--A State waiver may be approved for a 
     period of 5 years and may be extended for subsequent 5-year 
     periods upon approval by the Secretary, except that a shorter 
     period may be requested by a State and granted by the 
     Secretary.
       (d) Qualification for Federal Funds.--For purposes of this 
     Act, a State with an approved alternative health care system 
     under subsection (b)(2) shall be considered a participating 
     State and shall maintain such status if such State meets the 
     requirements established by the Secretary in the waiver 
     approval and in this section.
       (e) Evaluation, Monitoring, and Compliance.--
       (1) State health reform advisory board.--Within 90 days 
     after the date of the enactment of this Act, the Secretary 
     shall establish a 7-member State Health Reform Advisory Board 
     (hereafter in this subsection referred to as the ``Board'') 
     that will be responsible for monitoring the status and 
     progress achieved under waivers granted under this section 
     and promoting information exchange between States and the 
     Federal Government. The Board shall be comprised of members 
     representing relevant participants in State programs, 
     including representatives of State government, employers, 
     consumers, providers, and insurers. The Board shall also be 
     responsible for making recommendations to the Secretary, 
     using equivalency or minimum standards, for minimizing the 
     negative effect of State waivers on national employer groups, 
     provider organizations, and insurers because of differing 
     State requirements under the waivers.
       (2) Annual reports by states.--Each State that has received 
     a waiver approval shall submit to the Secretary an annual 
     report based on the period representing the respective 
     State's fiscal year, detailing compliance with the 
     requirements established by the Secretary in the waiver 
     approval and in this section.
       (3) Corrective action plans.--If a State is not in 
     compliance, the Secretary shall develop, in conjunction with 
     all the approved States, a corrective action plan.
       (4) Termination.--For good cause, the Secretary may revoke 
     any waiver of Federal law granted under this section, and if 
     necessary, may terminate any alternative State health 
     program. Such decisions shall be subject to a petition for 
     reconsideration and appeal pursuant to regulations 
     established by the Secretary.
       (5) Evaluations by secretary.--The Secretary shall prepare 
     and submit to the Committee on Finance and the Committee on 
     Labor and Human Resources of the Senate and the Committee on 
     Energy and Commerce and the Committee on Ways and Means of 
     the House of Representatives annual reports that shall 
     contain--
       (A) a description of the effects of the reforms undertaken 
     in States receiving waiver approvals under this section;
       (B) an evaluation of the effectiveness of such reforms in--
       (i) expanding health care coverage for State residents;
       (ii) providing health care to State residents with special 
     needs;
       (iii) reducing or containing health care costs in the 
     States; and
       (iv) improving the quality of health care provided in the 
     States; and
       (C) recommendations regarding the advisability of 
     increasing Federal financial assistance for State alternative 
     State health program initiatives, including the amount and 
     source of such assistance.
       (f) Funding.--
       (1) In general.--The Secretary may provide a grant to a 
     State that has an application for a waiver approved under 
     this section to enable such State to carry out an alternative 
     State health program in the State.
       (2) Amount of grant.--The amount of a grant provided to a 
     State under paragraph (1) shall be determined pursuant to an 
     allocation formula established by the Secretary.
       (3) Priority.--In awarding grants under paragraph (1), the 
     Secretary shall give priority to those State projects that 
     the Secretary determines have the greatest opportunity to 
     succeed in providing expanded health insurance coverage and 
     in providing children and youth with access to health care 
     items and services.
       (4) Maintenance of effort.--A State, in utilizing the 
     proceeds of a grant received under paragraph (1), shall 
     maintain the expenditures of the State for health care 
     coverage purposes 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. The requirement of this paragraph shall not apply 
     in the case of a State that desires to alter health care 
     coverage funding levels within the scope of the State's 
     alternative health program.
       (5) Report.--At the end of the 5-year period beginning on 
     the date on which the Secretary awards the first grant under 
     paragraph (1), the State Health Reform Advisory Board 
     established under subsection (e)(1) shall prepare and submit 
     to the appropriate committees of Congress, a report on the 
     progress made by States receiving grants under paragraph (1) 
     in achieving universal health care coverage in such States 
     during the 5-year period of the grant. Such report shall 
     contain the recommendation of the Board concerning any future 
     action that Congress should take concerning health care 
     reform, including whether or not to extend the program 
     established under this subsection.
       (g) Availability of Funds.--With respect to each of the 
     calendar years 1996 through 2000, $10,000,000,000 shall be 
     available for a calendar year to carry out this section from 
     the Health Care Reform Trust Fund established under section 
     9551(a)(2)(A) of the Internal Revenue Code of 1986. Amounts 
     made available in a calendar year under this paragraph and 
     not expended may be used in subsequent calendar years to 
     carry out this section.
       (h) Amendment to Criminal Penalties for Acts Involving 
     Medicare or State Health Care Programs.--Section 1128B(b) of 
     the Social Security Act (42 U.S.C. 1320a-7b(b)) is amended by 
     adding at the end the following new paragraph:
       ``(4) Paragraphs (1) and (2) shall not apply to--
       ``(A) any payment to a health insurer or health maintenance 
     organization for which the premium is paid in whole or in 
     part by a State health care program; and
       ``(B) any payment made by a health insurer or a health 
     maintenance organization to a sales representative or a 
     licensed insurance agent as compensation for the services of 
     the representative or agent in marketing and enrolling an 
     individual in a health plan for which the premium is paid in 
     whole or in part by a State health care program.''.
                    Subtitle B--Existing State Laws

     SEC. 2101. CONTINUANCE OF EXISTING FEDERAL LAW WAIVERS.

       Nothing in this Act shall preempt any feature of a State 
     health care system operating under a waiver granted before 
     the date of the enactment of this Act under titles XVIII or 
     XIX of the Social Security Act (42 U.S.C. 1395 et seq. or 
     1396 et seq.) or the Employee Retirement Income Security Act 
     of 1974 (29 U.S.C. 1001 et seq.).

     SEC. 2102. HAWAII PREPAID HEALTH CARE ACT.

       (a) ERISA Waiver.--
       (1) In general.--Section 514(b)(5) of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)) 
     is amended to read as follows:
       ``(5)(A) Except as provided in subparagraphs (B) and (C), 
     subsection (a) shall not apply to the Hawaii Prepaid Health 
     Care Act (Haw. Rev. Stat. Sec. Sec. 393-1 through 393-51).
       ``(B) Nothing in subparagraph (A) shall be construed to 
     exempt from subsection (a) any State tax law relating to 
     employee benefits plans.
       ``(C) If the Secretary of Labor notifies the Governor of 
     the State of Hawaii that as the result of an amendment to the 
     Hawaii Prepaid Health Care Act enacted after the date of the 
     enactment of this paragraph--
       ``(i) the proportion of the population with health care 
     coverage under such Act is less than such proportion on such 
     date, or
       ``(ii) the level of benefit coverage provided under such 
     Act is less than the actuarial equivalent of such level of 
     coverage on such date,

     subparagraph (A) shall not apply with respect to the 
     application of such amendment to such Act after the date of 
     such notification.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall take effect on the date of the enactment of this Act.
       (b) HSA Waiver.--
       (1) In general.--The Secretary shall, at the request of the 
     Governor of the State of Hawaii and in accordance with this 
     section, grant a waiver to the State from the requirements of 
     this Act (other than the requirements specified in paragraph 
     (3)).
       (2) Scope of waiver.--The waiver granted under paragraph 
     (1) shall exempt--
       (A) the State of Hawaii;
       (B) health plans offered within the State; and
       (C) health plan participants, including employers, 
     employees, residents, and health plan sponsors within the 
     State,

     from requirements otherwise applicable to the State and such 
     plans and participants.
       (3) Required compliance of other requirements.--The waiver 
     shall initially be granted under paragraph (1) if the State 
     of Hawaii demonstrates to the Secretary that the State 
     maintains--
       (A) a requirement that employers make premium contributions 
     in accordance with the requirements of title I;
       (B) a comprehensive benefit package (including cost 
     sharing) that is comparable with the requirements of title I;
       (C) a percentage of State population with health care 
     coverage that is not less than the national average;
       (D) a quality control mechanism and data system; and
       (E) health care cost containment consistent with the 
     provisions of title I.
       (4) Waiver period.--The waiver initially granted under 
     paragraph (1) shall extend for the period during which the 
     State of Hawaii continues to comply with the requirements 
     specified in paragraph (3). The Secretary may require the 
     State, every 5 years, to demonstrate to the Secretary the 
     State's continued compliance with such requirements.
       (5) Procedure in the event of non-compliance.--
       (A) Notice.--If, at any time after granting a waiver under 
     paragraph (1), the Secretary finds that the State of Hawaii 
     is not meeting the requirements specified in paragraph (3), 
     the Secretary shall notify the State of the Secretary's 
     findings.
       (B) Opportunity to contest.--The State may contest the 
     Secretary's findings.
       (C) Opportunity for correction.--
       (i) Findings not contested.--If the State does not contest 
     the Secretary's findings within the 30-day period beginning 
     on the date of receipt of a notice of such findings, the 
     State shall have--

       (I) a 90-day period beginning on such date to show a good 
     faith effort to remedy the non-compliance, and
       (II) an additional 12-month period to take such actions as 
     may be required to bring the State into compliance with the 
     requirements specified in paragraph (3).

       (ii) Contested findings.--If the State contests the 
     Secretary's findings within such 30-day period but such 
     findings are upheld, the State shall have--

       (I) a 90-day period beginning on the date of final 
     adjudication to show a good faith effort to remedy the non-
     compliance, and
       (II) an additional 12-month period to take such actions as 
     may be required to bring the State into compliance with the 
     requirements specified in paragraph (3).

       (D) Termination.--If the State fails to demonstrate a good 
     faith effort under subparagraph (C)(i)(I) or (C)(ii)(I) or to 
     take actions under subparagraph (C)(i)(II) or (C)(ii)(II) 
     within the time period specified, the Secretary may revoke 
     the waiver granted in paragraph (1).
       (6) Cooperative agreement with the secretary.--The 
     Secretary shall enter into cooperative agreements with 
     appropriate officials of the State of Hawaii--
       (A) to develop standards and reporting requirements 
     necessary for the issuance and maintenance of the State's 
     waiver under paragraph (1); and
       (B) otherwise to effectuate the provisions of this 
     subsection.
       (7) Eligibility for federal funds provided to participating 
     states.--Nothing in this subsection shall preclude the 
     eligibility of the State of Hawaii to participate in any 
     public health initiative, grant, or financial aid program 
     under this Act (including the medicaid program under title 
     XIX of the Social Security Act), designed to implement the 
     purpose of this Act. The Secretary shall work with 
     appropriate officials of the State of Hawaii to develop 
     comparable, alternative standards to govern the State's 
     entitlement under title XI.

     SEC. 2103. ALTERNATIVE STATE PROVIDER PAYMENT SYSTEMS.

       Notwithstanding any other provision of law, if a hospital 
     reimbursement system operated by a State meets the 
     requirements of section 1814(b) of the Social Security Act 
     (42 U.S.C. 1395f(b)) and has been approved by the Secretary 
     and in continuous operation since July 1, 1977, the payment 
     rates and methodologies required under the system for 
     services provided in the State shall apply to all purchasers 
     and payers, including those under employee welfare benefit 
     plans authorized under the Employee Retirement Income 
     Security Act of 1974 (29 U.S.C. 1001 et seq.), workers' 
     compensation programs under State law, the Federal Employees' 
     Compensation Act under chapter 81 of title 5, United States 
     Code, and Federal employee health benefit plans under chapter 
     89 of title 5, United States Code.

     SEC. 2104. ALTERNATIVE STATE HOSPITAL SERVICES PAYMENT 
                   SYSTEMS.

       (a) In General.--No State shall be prevented from 
     enforcing--
       (1) a State system described in subsection (b), or
       (2) a State system described in subsection (c),
     by any provision of the Employee Retirement Income Security 
     Act of 1974 (29 U.S.C. 1001 et seq.) or chapter 81 or 89 of 
     title 5, United States Code.
       (b) Reimbursement Control System.--A State system is 
     described in this subsection if it is a State reimbursement 
     control system in operation before the date of the enactment 
     of this Act which--
       (1) applies to substantially all non-Federal acute care 
     hospitals in the State, and
       (2) regulates substantially all rates of payment (including 
     maximum charges) in the State for inpatient hospital 
     services, except payments made under title XVIII of the 
     Social Security Act (42 U.S.C. 1395 et seq.).
       (c) Health Insurance Reform System.--A State system is 
     described in this subsection if it is a State health 
     insurance reform system in operation before the date of the 
     enactment of this Act which requires any insurer (including a 
     health maintenance organization) to comply with requirements 
     governing open enrollment and community rating, including 
     premium adjustments or other health care assessments for the 
     purpose of risk adjustment.
       (d) Effective Dates.--
       (1) Subsection (b).--In the case of a State system 
     described in subsection (b), the provisions of this section 
     shall apply before, on, and after the date of the enactment 
     of this Act.
       (2) Subsection (c).--In the case of a State system 
     described in subsection (c), the provisions of this section 
     shall apply before, on, and after the date of the enactment 
     of this Act, and before the date of enactment of this Act.

     SEC. 2105. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN 
                   PROVISIONS OF THE LAW OF THE STATE OF OREGON 
                   RELATING TO HEALTH PLANS.

       (a) In General.--Section 514(b) of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. 1144(b)) is amended by 
     adding at the end the following new paragraph:
       ``(9)(A) Subject to subparagraph (B), subsection (a) shall 
     not apply to the following provisions of the law of the State 
     of Oregon as applied to a group health plan:
       ``(i) Chapter 838, Oregon Laws 1989 (relating to the 
     creation and operation of a high-risk insurance pool).
       ``(ii) Chapter 591, Oregon Laws 1987, chapter 381, Oregon 
     Laws 1989, and chapter 916, Oregon Laws 1991 (relating to 
     employer-based health plan coverage reforms).
       ``(iii) Chapter 470, Oregon Laws 1991 (relating to health 
     care cost containment and technology assessment).
       ``(iv) Chapter 836, Oregon Laws 1989 and chapter 753, 
     Oregon Laws 1991 (relating to prioritization and medical 
     assistance reforms).
       ``(v) Chapter 815, Oregon Laws 1993 (relating to phasing in 
     of employer coverage and other revisions of the Oregon Health 
     Plan).
       ``(vi) Any other provision of the law of the State of 
     Oregon, to the extent that such provision is necessary to 
     achieve universal coverage under the Oregon Health Plan.
       ``(B) Subparagraph (A) shall apply with respect to any 
     provision of the law of the State of Oregon which provides, 
     directly or indirectly, for taxation of employers or group 
     health plans only if under such provision the assessment of 
     the tax is under a uniform schedule, applicable to all 
     employers and group health plans, and does not discriminate 
     on the basis of the extent to which a group health plan is 
     insured.
       ``(C) For purposes of this paragraph, the term `group 
     health plan' has the meaning provided in section 607(1).''.
       (b) Applicability of Federal Health Reform Legislation.--
     The State of Oregon shall not be treated as failing to comply 
     with applicable requirements of any Federal health reform 
     law, which is enacted on or after the date of the enactment 
     of this Act and which provides for coverage of individuals 
     under a comprehensive benefit package, before the first day 
     of the first calendar year following the calendar year in 
     which all other States have in effect plans under which 
     individuals are eligible for coverage under a comprehensive 
     benefit package in compliance with such law.

     SEC. 2106. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN 
                   PROVISIONS OF THE LAW OF THE STATE OF MINNESOTA 
                   RELATING TO HEALTH PLANS.

       (a) ERISA Waiver.--
       (1) In general.--Section 514(b)(5) of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)) 
     is amended to read as follows:
       ``(5)(A)(i) Except as provided in clauses (ii) and (iii), 
     subsection (a) shall not apply to the following provisions of 
     the law of the State of Minnesota:
       ``(I) Sections 295.50 through 295.59 Minnesota Statutes 
     relating to gross revenues, hospitals and health care 
     surgical centers and pass through of such tax.
       ``(II) Sections 62J.30 through 62.J.45 Minnesota Statutes 
     relating to data to the extent those provisions authorize or 
     require submission of data by health care providers, health 
     insurers, health maintenance organizations, or third party 
     administrators.
       ``(ii) Nothing in clause (i) shall be construed to exempt 
     from subsection (a)--
       ``(I) any State tax law relating to employee benefit plans 
     (other than a provision described in clause (i)), and
       ``(II) any amendment of any provision referred to in clause 
     (i) enacted on or after May 31, 1994; to the extent it 
     provides for more than the effective administration of such 
     provision as in effect on such date.
       ``(iii) Notwithstanding clause (i), parts 1 and 4 of this 
     subtitle, and the preceding sections of this part to the 
     extent they govern matters which are governed by the 
     provisions of such parts 1 and 4, shall supersede the 
     provisions described in clause (i) (as in effect on or after 
     May 31, 1994), but the Secretary may enter into cooperative 
     arrangements under this subparagraph and section 506 with 
     officials of the State of Minnesota to assist them in 
     effectuating the policies of such provisions which are 
     superseded by such parts 1 and 4 and the preceding sections 
     of this part.''.

     SEC. 2107. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN 
                   PROVISIONS OF THE LAW OF THE STATE OF 
                   WASHINGTON RELATING TO HEALTH PLANS.

       Section 514(b) of the Employee Retirement Income Security 
     Act of 1974 (29 U.S.C. 1144(b)) is amended by adding at the 
     end of the following new paragraph:
       ``(9) Subsection (a) of this section shall not apply to the 
     following provisions of the law of the State of Washington--
       ``(A) section 212 of Chapter 492, Laws of 1993 (relating to 
     enrollment of certain employees in the Washington basic 
     health plan);
       ``(B) sections 301 and 304 of Chapter 492, Laws of 1993 
     (relating to taxation of premiums and hospitals);
       ``(C) sections 406(7) and 454 of Chapter 492, Laws of 1993 
     (relating to medical risk adjustment mechanisms);
        ``(D) section 427 of Chapter 492, Laws of 1993 (relating 
     to benefits required to be offered by registered employer 
     health plans);
       ``(E) section 430 of Chapter 492, Laws of 1993 (relating to 
     requirements applicable to registered employer health plans); 
     and
       ``(F) section 464 of Chapter 492, Laws of 1993, as amended 
     by section 3 of Chapter 494, Laws of 1993 (relating to 
     requirements that employers offer and pay a portion of the 
     costs of employee health care coverage).''.

     SEC. 2108. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN 
                   PROVISIONS OF THE LAW OF THE STATE OF 
                   CONNECTICUT RELATING TO HEALTH PLANS.

       Section 514(b) of the Employee Retirement Income Security 
     Act (29 U.S.C. 1144(b)) is amended by adding at the end of 
     the following new subsection:
       ``(9) Subsection (a) of this section shall not apply to any 
     State law enacted in the State of Connecticut in accordance 
     with Public Law 102-234 which taxes or otherwise assesses 
     short-term acute care hospitals for the purpose of providing 
     funds to be used to pay for the cost of uncompensated care. 
     This subsection shall take effect January 1, 1992.''.
 TITLE III--PUBLIC HEALTH AND RURAL AND UNDERSERVED ACCESS IMPROVEMENT

     SEC. 3001. SHORT TITLE.

       This title may be cited as the ``Public Health and Rural 
     and Underserved Access Improvement Act of 1994''.

     SEC. 3002. ESTABLISHMENT OF NEW TITLE XXVII REGARDING PUBLIC 
                   HEALTH PROGRAMS.

       The Public Health Service Act (42 U.S.C. 201 et seq.) is 
     amended by adding at the end the following title:
           ``TITLE XXVII--PUBLIC HEALTH PROGRAMS IMPROVEMENT
         ``Subtitle A--Core Functions of Public Health Programs

                   ``PART 1--FORMULA GRANTS TO STATES

     ``SEC. 2711. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this subtitle, there are 
     authorized to be appropriated from the Health Care Reform 
     Trust Fund established under section 9551(a)(2)(A) of the 
     Internal Revenue Code of 1986 (hereafter referred to in this 
     title as the ``Fund''), $200,000,000 for fiscal year 1996, 
     $350,000,000 for fiscal year 1997, $500,000,000 for fiscal 
     year 1998, $650,000,000 for fiscal year 1999, and 
     $700,000,000 for fiscal year 2000.

     ``SEC. 2712. FORMULA GRANTS TO STATES FOR CORE HEALTH 
                   FUNCTIONS.

       ``(a) In General.--In the case of each State that submits 
     to the Secretary an application in accordance with section 
     2715 for a fiscal year, the Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention, shall make a grant to the 
     State for carrying out the activities described in subsection 
     (c). The award shall consist of the allotment determined 
     under section 2716 for the State.
       ``(b) General Purpose.--The purpose of this subtitle is to 
     provide for improvements in the health status of the public 
     through carrying out the activities described in subsection 
     (b) toward attaining the Healthy People 2000 Objectives (as 
     defined in section 2799). A funding agreement for a grant 
     under subsection (a) is that--
       ``(1) the grant will be expended for such activities; and
       ``(2) the activities will be carried out by the State in 
     collaboration with local public health departments, health 
     education and training centers, neighborhood health centers, 
     and other community health providers.
       ``(c) Core Functions of Public Health Programs.--Subject to 
     the purpose described in subsection (b), the activities 
     referred to in subsection (a) are the following:
       ``(1) Data collection, and analytical activities, related 
     to population-based status and outcomes monitoring, including 
     the following:
       ``(A) The regular collection and analysis of public health 
     data (including the 10 leading causes of death and their 
     costs to society).
       ``(B) Vital statistics.
       ``(C) Personal health services data.
       ``(D) The supply and distribution of health professionals.
       ``(2) Activities to reduce environmental risk and to assure 
     the safety of housing, schools, workplaces, day-care centers, 
     food and water, including the following activities:
       ``(A) Monitoring the overall public health status and 
     safety of communities.
       ``(B) Assessing exposure to high lead levels and other 
     environmental contaminants; and activities for abatement of 
     toxicant hazards, including lead-related hazards.
       ``(C) Monitoring the quality of community water supplies 
     used for consumption or for recreational purposes.
       ``(D) Monitoring sewage and solid waste disposal, radiation 
     exposure, radon exposure, and noise levels.
       ``(E) Monitoring indoor and ambient air quality and related 
     risks to vulnerable populations.
       ``(F) Assuring recreation, worker, and school safety.
       ``(G) Enforcing public health safety and sanitary codes.
       ``(H) Monitoring community access to appropriate health 
     services.
       ``(I) Other activities relating to promoting and protecting 
     the public health of communities.
       ``(3) Investigation, control, and public-awareness 
     activities regarding adverse health conditions (such as 
     emergency treatment preparedness, community efforts to reduce 
     violence, outbreaks of communicable diseases within 
     communities, chronic disease and dysfunction exposure-related 
     conditions, toxic environmental pollutants, occupational and 
     recreational hazards, motor vehicle accidents, and other 
     threats to the health status of individuals).
       ``(4) Public information and education programs to reduce 
     risks to health (such as use of tobacco;, alcohol and other 
     drugs; unintentional injury from accidents, including motor 
     vehicle accidents; sexual activities that increase the risk 
     to HIV transmission and sexually transmitted diseases; poor 
     diet; physical inactivity; stress-related illness; mental 
     health problems; genetic disorders; and low childhood 
     immunization levels).
       ``(5) Provision of public health laboratory services to 
     complement private clinical laboratory services and that 
     screen for diseases and conditions (such as metabolic 
     diseases in newborns, provide assessments of blood lead 
     levels and other environmental toxicants, diagnose and 
     contact tracing of sexually transmitted diseases, 
     tuberculosis and other diseases requiring partner 
     notification, test for infectious and food-borne diseases, 
     and monitor the safety of water and food supplies).
       ``(6) Training and education of new and existing health 
     professionals in the field of public health, with special 
     emphasis on epidemiology, biostatistics, health education, 
     public health administration, public health nursing and 
     dentistry, environmental and occupational health sciences, 
     public health nutrition, social and behavioral health 
     sciences, operations research, and laboratory technology.
       ``(7) Leadership, policy development and administration 
     activities, including assessing needs and the supply and 
     distribution of health professionals; the setting of public 
     health standards; the development of community public health 
     policies; and the development of community public health 
     coalitions.
       ``(d) Restrictions on Use of Grant.--
       ``(1) In general.--A funding agreement for a grant under 
     subsection (a) for a State is that the grant will not be 
     expended--
       ``(A) to provide inpatient services;
       ``(B) to make cash payments to intended recipients of 
     health services;
       ``(C) to purchase or improve land, purchase, construct, or 
     permanently improve (other than minor remodeling) any 
     building or other facility, or purchase major medical 
     equipment;
       ``(D) to satisfy any requirement for the expenditure of 
     non-Federal funds as a condition for the receipt of Federal 
     funds; or
       ``(E) to provide financial assistance to any entity other 
     than a public or nonprofit private entity.
       ``(2) Limitation on administrative expenses.--A funding 
     agreement for a grant under subsection (a) is that the State 
     involved will not expend more than 20 percent of the grant 
     for administrative expenses with respect to the grant.
       ``(e) Maintenance of Effort.--A funding agreement for a 
     grant under subsection (a) is that the State involved will 
     maintain expenditures of non-Federal amounts for core health 
     functions at a level that is not less than the level of such 
     expenditures maintained by the State for the fiscal year 
     preceding the first fiscal year for which the State receives 
     such a grant.

     ``SEC. 2713. NUMBER OF FUNCTIONS; PLANNING.

       ``(a) Number of Functions.--Subject to subsection (b), a 
     funding agreement for a grant under section 2712 is that the 
     State involved will carry out each of the activities 
     described in subsection (c) of such section.
       ``(b) Planning.--In making grants under section 2712, the 
     Secretary shall for each State designate a period during 
     which the State is to engage in planning to meet the 
     responsibilities of the State under subsection (a). The 
     period so designated may not exceed 18 months. With respect 
     to such period for a State, a funding agreement for a grant 
     under section 2712 for any fiscal year containing any portion 
     of the period is that, during the period, the State will 
     expend the grant only for such planning.

     ``SEC. 2714. SUBMISSION OF INFORMATION; REPORTS.

       ``(a) Submission of Information.--The Secretary may make a 
     grant under section 2712 only if the State involved submits 
     to the Secretary the following information:
       ``(1) A description of the relationship between community 
     health providers, public and private health plans, and the 
     public health system of the State.
       ``(2) A description of existing deficiencies in the public 
     health system at the State level and the local level, using 
     standards under the Healthy People 2000 Objectives.
       ``(3) A description of public health priorities identified 
     at the State level and local levels, including the 10 leading 
     causes of death and their respective direct and indirect 
     costs to the State and the Federal Government.
       ``(4) Measurable outcomes and process objectives (using 
     criteria under the Healthy People 2000 Objectives) which 
     indicate improvements in health status as a result of the 
     activities carried out under section 2712(c).
       ``(5) Information regarding each such activity, which--
       ``(A) identifies the amount of State and local funding 
     expended on each such activity for the fiscal year preceding 
     the fiscal year for which the grant is sought; and
       ``(B) provides a detailed description of how additional 
     Federal funding will improve each such activity by both the 
     State and local public health agencies.
       ``(6) A description of activities under section 2712(c) to 
     be carried out at the local level, and a specification for 
     each such activity of--
       ``(A) the communities in which the activity will be carried 
     out and any collaborating agencies; and
       ``(B) the amount of the grant to be expended for the 
     activity in each community so specified.
       ``(7) A description of how such activities have been 
     coordinated with activities supported under title V of the 
     Social Security Act (relating to maternal and child health).
       ``(b) Reports.--A funding agreement for a grant under 
     section 2712 is that the States involved will, not later than 
     the date specified by the Secretary, submit to the Secretary 
     a report describing--
       ``(1) the purposes for which the grant was expended;
       ``(2) the health status of the population of the State, as 
     measured by criteria under the Healthy People 2000 
     Objectives; and
       ``(3) the progress achieved and obstacles encountered in 
     using uniform data sets under such Objectives.

     ``SEC. 2715. APPLICATION FOR GRANT.

       ``The Secretary may make a grant under section 2712 only if 
     an application for the grant is submitted to the Secretary, 
     the application contains each agreement described in this 
     part, the application contains the information required in 
     section 2712(c), and the application is in such form, is made 
     in such manner, and contains such agreements, assurances, and 
     information as the Secretary determines to be necessary to 
     carry out this part.

     ``SEC. 2716. DETERMINATION OF AMOUNT OF ALLOTMENT.

       ``For purposes of section 2712, the allotment under this 
     section for a State for a fiscal year shall be determined 
     through a formula established by the Secretary on the basis 
     of the population, economic indicators, and health status of 
     each State. Such allotment shall be the product of--
       ``(1) a percentage determined under the formula; and
       ``(2) the amount appropriated under section 2711 for the 
     fiscal year, less any amounts reserved under section 2717.

     ``SEC. 2717. ALLOCATIONS FOR CERTAIN ACTIVITIES.

       ``Of the amounts made available under section 2711 for a 
     fiscal year for carrying out this part, the Secretary may 
     reserve not more than 15 percent for carrying out the 
     following activities:
       ``(1) Technical assistance with respect to planning, 
     development, and operation of activities under section 
     2712(b), including provision of biostatistical and 
     epidemiological expertise, provision of laboratory expertise, 
     and the development of uniform data sets under the Health 
     People 2000 Objectives.
       ``(2) Development and operation of a national information 
     network among State and local health agencies for utilizing 
     such uniform data sets.
       ``(3) Program monitoring and evaluation of activities 
     carried out under section 2712(b).
       ``(4) Development of a unified electronic reporting 
     mechanism to improve the efficiency of administrative 
     management requirements regarding the provision of Federal 
     grants to State public health agencies.

  ``PART 2--COMPREHENSIVE EVALUATION OF DISEASE PREVENTION AND HEALTH 
                           PROMOTION PROGRAMS

     ``SEC. 2718. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this part, there are 
     authorized to be appropriated from the Fund, $100,000,000 for 
     fiscal year 1996, and $150,000,000 for each of the fiscal 
     years 1997 through 2000.

     ``SEC. 2719. EVALUATION OF PROGRAMS.

       ``(a) Grants.--The Secretary may make grants to, or enter 
     into cooperative agreements or contracts with, eligible 
     entities for the purpose of enabling such entities to carry 
     out evaluations of the type described in subsection (c). The 
     Secretary shall carry out this section acting through the 
     Director of the Centers for Disease Control and Prevention, 
     subject to subsection (g).
       ``(b) Requirements.--
       ``(1) Eligible entities.--To be eligible to receive an 
     award of a grant, cooperative agreement, or contract under 
     subsection (a), an entity must--
       ``(A) be a public, nonprofit, or private entity or a 
     university;
       ``(B) prepare and submit to the Secretary an application at 
     such time, in such form, and containing such information as 
     the Secretary may require, including a plan for the conduct 
     of the evaluation under the grant;
       ``(C) provide assurances that any information collected 
     while conducting evaluations under this section will be 
     maintained in a confidential manner with respect to the 
     identities of the individuals from which such information is 
     obtained; and
       ``(D) meet any other requirements that the Secretary 
     determines to be appropriate.
       ``(2) Types of entities.--In making awards under subsection 
     (a), the Secretary shall consider applications from entities 
     proposing to conduct evaluations using community programs, 
     managed care programs, State and county health departments, 
     public education campaigns, school programs, and other 
     appropriate programs. The Secretary shall ensure that not 
     less than 25 percent of the amounts appropriated under 
     section 2718 for a fiscal year are used for making such 
     awards to entities that will use the amounts to conduct 
     evaluations in the workplace.
       ``(c) Use of Funds.--
       ``(1) Evaluations.--An award under subsection (a) shall be 
     used to--
       ``(A) conduct evaluations to determine the extent to which 
     clinical preventive services, health promotion and 
     unintentional injury prevention activities, and interpersonal 
     and community violence prevention activities, achieve short-
     term and long-term health care cost reductions and health 
     status improvement with respect to the Healthy People 2000 
     Objectives; and
       ``(B) evaluate other areas determined appropriate by the 
     Secretary.
       ``(2) Inclusion of certain population groups.--In carrying 
     out this section, the Secretary shall ensure that data 
     concerning women, children, minorities, older individuals 
     with different income levels, retirees, and individuals from 
     diverse geographical backgrounds, are obtained.
       ``(3) Minimum services.--The evaluations that the Secretary 
     may provide for under this section include (but are not 
     limited to) evaluations of programs that provide one or more 
     of the following services:
       ``(A) Blood pressure screening and control (to detect and 
     control hypertension and coronary health disease).
       ``(B) Early cancer screening.
       ``(C) Blood cholesterol screening and control.
       ``(D) Smoking cessation programs.
       ``(E) Substance abuse programs.
       ``(F) Dietary and nutrition counseling, including 
     nutrition.
       ``(G) Physical fitness counseling.
       ``(H) Stress management.
       ``(I) Diabetes education and screening.
       ``(J) Intraocular pressure screening.
       ``(K) Monitoring of prescription drug use.
       ``(L) Violence and injury prevention programs.
       ``(M) Health education.
       ``(N) Immunization rates.
       ``(4) Environmental data.--Evaluations conducted under this 
     section may consider the health effects and cost-
     effectiveness of certain environmental programs, including 
     fluoridation programs, traffic safety programs, pollution 
     control programs, accident prevention programs, and 
     antismoking programs.
       ``(5) Public policies.--Evaluations conducted under this 
     section may consider the effects of prevention-oriented 
     social and economic policies on improvement of health status 
     and their long-term cost effectiveness.
       ``(6) Use of existing data.--In conducting evaluations 
     under this section, entities shall use existing data and 
     health promotion and screening programs where practicable.
       ``(7) Cooperation.--In providing for an evaluation under 
     this section, the Secretary shall encourage the recipient of 
     the award and public and private entities with relevant 
     expertise (including State and local agencies) to collaborate 
     for purposes of conducting the evaluation.
       ``(d) Sites.--Recipients of awards under subsection (a) 
     shall select evaluation sites under the award that present 
     the greatest potential for new and relevant knowledge. Such 
     recipients, in selecting such sites, shall ensure that--
       ``(1) the sites provide evidence of pilot testing, process 
     evaluation, formative evaluation, availability assessment 
     strategies and results;
       ``(2) the sites provide evidence of a clear definition of 
     the program and protocols for the implementation of the 
     evaluation; and
       ``(3) the sites provide evidence of valid, appropriate and 
     feasible assessment methods and tools and a willingness to 
     use common data items and instruments across such sites.
       ``(e) Reporting Requirements.--Not later than 1 year after 
     an entity first receives an award under subsection (a), and 
     not less than once during each 1-year period thereafter for 
     which such an award is made to the entity, the entity shall 
     prepare and submit to the Secretary a report containing a 
     description of the activities under this section conducted 
     during the period for which the report is prepared, and the 
     findings derived as a result of such activities.
       ``(f) Term of Evaluations.--Evaluations conducted under 
     this section shall be for a period of not less than 3 years 
     and may continue as necessary to permit the grantee to 
     adequately measure the full benefit of the evaluations.
       ``(g) Dissemination and Guidelines.--
       ``(1) Consultation.--The Secretary shall carry out this 
     subsection acting through the Director of the Centers for 
     Disease Control and Prevention and the Administrator for 
     Health Care Policy and Research.
       ``(2) Guidelines.--The Secretary shall, where feasible and 
     practical, develop and issue practice guidelines that are 
     based on the results of evaluations conducted under this 
     section. The practice guidelines shall be developed by the 
     Secretary utilizing expert practitioners to assist in the 
     development and implementation of these guidelines.
       ``(3) Data.--
       ``(A) In general.--The Secretary shall collect, store, 
     analyze, and make available data related to the formulation 
     of the guidelines that is provided to the Centers for Disease 
     Control and Prevention by entities conducting evaluations 
     under this section.
       ``(B) Use of data.--The Secretary shall--
       ``(i) identify activities that prevent disease, illness, 
     injury and disability, and promote good health practices; 
     ascertain their cost-effectiveness; and identify their 
     potential to overall health status with respect to Healthy 
     People 2000 Objectives;
       ``(ii) disseminate practice guidelines to State and county 
     health departments, State insurance departments, insurance 
     companies, employers, professional medical organizations, and 
     others determined appropriate by the Secretary; and
       ``(iii) provide information with respect to recidivism 
     rates of participation in the evaluations.
       ``(4) Dissemination.--The Secretary may disseminate 
     information collected from evaluations under this section.
       ``(h) Limitation.--Amounts appropriated for carrying out 
     this section shall not be utilized to provide services.
``Subtitle B--Opportunities for Education and Training in Public Health

``PART 1--SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS REGARDING SERVICE IN 
                        PUBLIC HEALTH POSITIONS

     ``SEC. 2721. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this part, there are 
     authorized to be appropriated from the Fund, $50,000,000 for 
     each of the fiscal years 1996 through 2000.

     ``SEC. 2722. SCHOLARSHIP PROGRAM.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     Centers for Disease Control and Prevention, shall carry out a 
     program under which the Secretary awards scholarships to 
     individuals described in subsection (b) for the purpose of 
     assisting the individuals with the costs of attending public 
     and nonprofit private schools of public health (or other 
     public or nonprofit private institutions providing graduate 
     or specialized training in public health).
       ``(b) Eligible Individuals.--An individual referred to in 
     subsection (a) is any individual meeting the following 
     conditions:
       ``(1) The individual is enrolled (or accepted for 
     enrollment) at a school or other institution referred to in 
     subsection (a) as a full-time or part-time student in a 
     program providing training in a health profession in a field 
     of public health (including the fields of epidemiology, 
     biostatistics, environmental health, health administration 
     and planning, behavioral sciences, maternal and child health, 
     occupational safety, public health nursing, nutrition, and 
     toxicology).
       ``(2) The individual enters into the contract required 
     pursuant to subsection (d) as a condition of receiving the 
     scholarship (relating to an agreement to provide services in 
     approved public health positions, as defined in section 
     2724).
       ``(c) Eligible Schools.--For fiscal year 1996 and 
     subsequent fiscal years, the Secretary may make an award of a 
     scholarship under subsection (a) only if the Secretary 
     determines that--
       ``(1) the school or other institution with respect to which 
     the award is to be provided has coordinated the activities of 
     the school or institution with relevant activities of the 
     Health Resources and Services Administration and the Centers 
     for Disease Control and Prevention; and
       ``(2) not fewer than 60 percent of the graduates of the 
     school or institution are in public health positions 
     determined by the Secretary to be consistent with the needs 
     of the United States regarding such professionals.
       ``(d) Applicability of Certain Provisions.--Except as 
     inconsistent with this section or section 2724, the 
     provisions of subpart III of part D of title III (relating to 
     the Scholarship and Loan Repayment Programs of the National 
     Health Service Corps) apply to an award of a scholarship 
     under subsection (a) to the same extent and in the same 
     manner as such provisions apply to an award of a scholarship 
     under section 338A.

     ``SEC. 2723. LOAN REPAYMENT PROGRAM.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     Centers for Disease Control and Prevention, shall carry out a 
     program under which the Federal Government enters into 
     agreements to repay all or part of the educational loans of 
     individuals meeting the following conditions:
       ``(1) The individual involved is a graduate of a school or 
     other institution described in section 2722(a).
       ``(2) The individual meets the applicable legal 
     requirements to provide services as a public health 
     professional (including a professional in any of the fields 
     specified in section 2722(b)(1)).
       ``(3) The individual enters into the contract required 
     pursuant to subsection (b) as a condition of the Federal 
     Government repaying such loans (relating to an agreement to 
     provide services in approved public health positions, as 
     defined in section 2724).
       ``(b) Applicability of Certain Provisions.--Except as 
     inconsistent with this section or section 2724, the 
     provisions of subpart III of part D of title III (relating to 
     the Scholarship and Loan Repayment Programs of the National 
     Health Service Corps) apply to an agreement regarding 
     repayment under subsection (a) to the same extent and in the 
     same manner as such provisions apply to an agreement 
     regarding repayment under section 338B.
       ``(c) Amount of Repayments.--For each year for which an 
     individual contracts to serve in an approved public health 
     position pursuant to subsection (b), the Secretary may repay 
     not more than $20,000 of the principal and interest of the 
     educational loans of the individual.

     ``SEC. 2724. APPROVED PUBLIC HEALTH POSITIONS.

       ``(a) Position Regarding Populations With Significant Need 
     for Services.--
       ``(1) In general.--With respect to the programs under this 
     part, the obligated service of a program participant pursuant 
     to sections 2722(d) and 2723(b) shall be provided through an 
     assignment, to an entity described in subsection (b), for a 
     position in which the participant provides services as a 
     public health professional to a population determined by the 
     Secretary to have a significant unmet need for the services 
     of such a professional.
       ``(2) Period of service.--For purposes of sections 2722(d) 
     and 2723(d), the period of obligated service is the 
     following, as applicable to the program participant involved:
       ``(A) In the case of scholarships under section 2722 for 
     full-time students, the greater of--
       ``(i) 1 year for each year for which such a scholarship is 
     provided; or
       ``(ii) 2 years.
       ``(B) In the case of scholarships under section 2722 for 
     part-time students, a period determined by the Secretary on 
     the basis of the number of hours of education or training 
     received under the scholarship, considering the percentage 
     constituted by the ratio of such number to the number of 
     hours for a full-time student in the program involved.
       ``(C) In the case of the loan repayments under section 
     2723, such period as the Secretary and the participant may 
     agree, except that the period may not be less than 2 years.
       ``(b) Approval of Entities for Assignment of Program 
     Participants.--The entities referred to in subsection (a) are 
     public and nonprofit private entities approved by the 
     Secretary as meeting such requirements for the assignment of 
     a program participant as the Secretary may establish. The 
     entities that the Secretary may so approve include State and 
     local departments of health, public hospitals, community and 
     neighborhood health clinics, migrant health clinics, 
     community-based health-related organizations, certified 
     regional poison control centers, purchasing cooperatives 
     regarding health insurance, and any other public or nonprofit 
     private entity.
       ``(c) Definitions.--For purposes of this part:
       ``(1) The term `approved public health position', with 
     respect to a program participant, means a position to which 
     the participant is assigned pursuant to subsection (a).
       ``(2) The term `program participant' means an individual 
     who enters into a contract pursuant to section 2722(b)(2) or 
     2723(a)(3).

     ``SEC. 2725. ALLOCATION OF FUNDS; SPECIAL CONSIDERATIONS.

       ``(a) Allocations Regarding New Participants in Scholarship 
     Program.--Of the amounts appropriated under section 2721 for 
     a fiscal year, the Secretary shall obligate not less than 30 
     percent for the purpose of providing awards for scholarships 
     under section 2722 to individuals who have not previously 
     received such scholarships.
       ``(b) Special Consideration for Certain Individuals.--In 
     making awards of scholarships under section 2722 and making 
     repayments under section 2723, the Secretary shall give 
     special consideration to individuals who are in the armed 
     forces of the United States or who are veterans of the armed 
     forces.

       ``PART 2--EDUCATIONAL INSTITUTIONS REGARDING PUBLIC HEALTH

     ``SEC. 2731. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this part from the Fund, 
     there are authorized to be appropriated from the Fund, 
     $100,000,000 for each of the fiscal years 1996 through 2000.

     ``SEC. 2732. GRANTS FOR EXPANDING CAPACITY OF INSTITUTIONS.

       ``(a) In General.--The Secretary may make grants to 
     institutions described in subsection (b) for the purpose of 
     expanding the educational capacities of the institutions 
     through recruiting and retaining faculty, curriculum 
     development, and coordinating the activities of the 
     institutions regarding education, training, and field 
     placements.
       ``(b) Relevant Institutions.--The institutions referred to 
     in subsection (a) are public and nonprofit private--
       ``(1) schools of public health;
       ``(2) departments of community and preventive medicine 
     that--
       ``(A) are within schools of medicine and schools of 
     osteopathic medicine; and
       ``(B) have established formal arrangements with schools of 
     public health in order to award joint degrees in public 
     health and another health profession; and
       ``(3) schools of nursing or dentistry that have established 
     formal arrangements with schools of public health in order to 
     carry out educational programs in public health at the 
     schools of nursing or dentistry, respectively.
       ``(c) Requirements Regarding Curriculum Development.--A 
     funding agreement for a grant under subsection (a) for an 
     institution is that, to the extent determined to be 
     appropriate by the Secretary, the curriculum of institution 
     will include the following:
       ``(1) Subject to subsection (d)(1), part-time nondegree 
     programs for public health professionals who need further 
     training in fields of public health.
       ``(2) With respect to the program of community health 
     advisors established in part 5 of subtitle E, a program to 
     train individuals to serve as supervisors under such part 
     (including training and evaluating the community health 
     advisors), which program is carried out in collaboration with 
     local public health departments and health education and 
     training centers.
       ``(3) A program under which the institution collaborates 
     with health departments and elementary and secondary schools 
     to develop a health education curriculum for use in the 
     program established under subtitle B of the Public Health 
     Improvement Act of 1994.
       ``(d) Additional Requirements.--Funding agreements for a 
     grant under subsection (a) for an institution are as follows:
       ``(1) In developing the curriculum under the grant, the 
     institution will consult with the health departments in the 
     State involved, and will follow the relevant priorities of 
     such departments.
       ``(2) The institution will, as appropriate in the 
     determination of the Secretary, coordinate the activities of 
     the institution under the grant with relevant activities of 
     the Health Resources and Services Administration and the 
     Centers for Disease Control and Prevention.

     ``SEC. 2733. COORDINATION OF GRANT ACTIVITIES WITH NATIONAL 
                   PRIORITIES.

       ``The Secretary shall--
       ``(1) determine the needs of the United States regarding 
     the education and geographic distribution of public health 
     professionals;
       ``(2) determine priorities among such needs; and
       ``(3) in making grants under section 2732, ensure that the 
     curricula developed under such section, and the expertise of 
     the faculty recruited and retained under such section, are 
     consistent with such priorities.

     ``SEC. 2734. CERTAIN REQUIREMENTS FOR GRANTS.

       ``For fiscal year 1997 and subsequent fiscal years, the 
     Secretary may make a grant under section 2732 only if the 
     institution involved is in compliance with the following:
       ``(1) The institution has coordinated the activities of the 
     school or institution with relevant activities of the Health 
     Resources and Services Administration and the Centers for 
     Disease Control and Prevention.
       ``(2) A significant number of the faculty of the 
     institution has served as practitioners in public health.
       ``(3) The institution has consulted with public health 
     departments and public hospital systems in the State involved 
     in order to develop a curriculum that reflects the needs and 
     priorities of the State regarding the public health.
       ``(4) The institution has coordinated the activities of the 
     institution with the activities of the health departments and 
     of community groups.
       ``(5) The institution carries out a program for part-time 
     students to receive training in fields of public health.
       ``(6) Not less than 60 percent of the graduates of the 
     school or institution are in public health positions 
     determined by the Secretary to be consistent with the needs 
     of the United States regarding such professionals.

           ``PART 3--EXPANSION OF COMPETENCY IN PUBLIC HEALTH

     ``SEC. 2736. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this section, there is 
     authorized to be appropriated from the Fund, $60,000,000 for 
     each of the fiscal years 1996 through 2000.

     ``SEC. 2737. GRANTS TO STATES.

       ``(a) States Lacking Adequate Training Programs.--
       ``(1) In general.--The Secretary may make grants to States 
     in which there is one or no program of training in a field of 
     public health but in which there are 1 or more schools of 
     medicine, osteopathic medicine, nursing, dentistry, social 
     work, pharmacy, or health administration. A funding agreement 
     for such a grant is that the purpose of the grant is for the 
     State involved to assist 1 or more of such schools in 
     developing and integrating public health curricula for the 
     schools.
       ``(2) Special considerations in making grants.--In making 
     grants under paragraph (1), the Secretary shall give special 
     consideration to States that agree to consult with 1 or more 
     schools of public health in carrying out the purpose 
     described in such subsection.
       ``(b) States With Nonaccredited Schools.--The Secretary may 
     make grants to States in which there are 1 or more 
     nonaccredited schools of public health. A funding agreement 
     for such a grant is that the purpose of the grant is for the 
     State involved to assist 1 or more of such schools in 
     improving the schools.
       ``(c) Amount of Grant; Limitation Regarding Individual 
     Educational Entities.--
       ``(1) Amount.--The amount of a grant under this section to 
     a State may not exceed $6,000,000.
       ``(2) Limitation.--A funding agreement for a grant under 
     this section for a State is that, with respect to the school 
     involved, the State will not provide more than 2 years of 
     assistance to the school from grants under this section.

                ``PART 4--AREA HEALTH EDUCATION CENTERS

     ``SEC. 2738. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``(a) Additional Funding.--For the purpose of carrying out 
     programs under section 746, there are authorized to be 
     appropriated from the Fund, $35,000,000 for each of the 
     fiscal years 1996 through 2000.
       ``(b) Relation to Other Funds.--The authorizations of 
     appropriations established in subsection (a) are in addition 
     to any other authorizations of appropriations that are 
     available for the purpose described in such subsection.

               ``PART 5--HEALTH EDUCATION TRAINING CENTER

     ``SEC. 2739. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``(a) Additional Funding.--For the purpose of carrying out 
     Health Education Training Center programs, there are 
     authorized to be appropriated from the Fund, $20,000,000 for 
     each of the fiscal years 1996 through 2000.
       ``(b) Relation to Other Funds.--The authorizations of 
     appropriations established in subsection (a) are in addition 
     to any other authorizations of appropriations that are 
     available for the purpose described in such subsection.
             ``Subtitle C--Regional Poison Control Centers

     ``SEC. 2741. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this subtitle, there is 
     authorized to be appropriated from the Fund, $50,000,000 for 
     each of the fiscal years 1996 through 2000.

     ``SEC. 2742. GRANTS FOR REGIONAL CENTERS.

       ``(a) In General.--The Secretary may make grants to public 
     and nonprofit private entities for centers to carry out 
     activities regarding--
       ``(1) the prevention and treatment of poisoning; and
       ``(2) such other activities regarding the control of 
     poisons as the Secretary determines to be appropriate.
       ``(b) Regional Considerations.--In making grants under 
     subsection (a), the Secretary shall determine the need in 
     each of the principal geographic regions of the United States 
     for a center under such subsection, and shall make the grants 
     according to priorities established by the Secretary on the 
     basis of the extent of such need in each of the regions. In 
     carrying out the preceding sentence, the Secretary shall 
     ensure that no two centers receive grants for the same 
     geographic service area.
       ``(c) Matching Funds.--
       ``(1) In general.--With respect to the costs of an entity 
     in providing for centers under subsection (a), the Secretary 
     may make a grant under such subsection only if the State in 
     which the center is to operate, or other public entities in 
     the State, agree to make available (directly or through 
     donations from public or private entities) non-Federal 
     contributions toward such costs in an amount determined by 
     the Secretary.
       ``(2) Determination of amount contributed.--Non-Federal 
     contributions required under paragraph (1) may be in cash or 
     in kind, fairly evaluated, including plant, equipment, or 
     services. Amounts provided by the Federal Government, or 
     services assisted or subsidized to any significant extent by 
     the Federal Government, may not be included in determining 
     the amount of such non-Federal contributions.

     ``SEC. 2743. REQUIREMENTS REGARDING CERTIFICATION.

       ``(a) In General.--Subject to subsection (b), the Secretary 
     may make a grant under section 2742 only if the center 
     involved has been certified by a professional organization in 
     the field of poison control, and the Secretary has approved 
     the organization as having in effect standards for 
     certification that reasonably provide for the protection of 
     the public health with respect to poisoning. In carrying out 
     the preceding sentence, the Secretary shall consider the 
     standards established by the American Association of Poison 
     Control Centers.
       ``(b) Temporary Waiver.--The Secretary may waive the 
     requirement of subsection (a) for a center for a period not 
     exceeding 1 year.

     ``SEC. 2744. GENERAL PROVISIONS.

       ``(a) Duration of Grant.--The period during which payments 
     are made under a grant under section 2742 may not exceed 3 
     years. The provision of such payments is subject to annual 
     approval by the Secretary of the payments and subject to the 
     availability of appropriations for the fiscal year involved 
     to make the payments. The preceding sentence may not be 
     construed as establishing a limitation on the number of such 
     grants that may be made to an entity.
       ``(b) Study Regarding Need for Centers.--
       ``(1) In general.--The Secretary shall conduct a study of 
     each of the centers for which a grant under section 2742 has 
     been provided. The purpose of the study shall be to determine 
     the effectiveness of the centers in carrying out the 
     activities described in such section and the extent to which 
     the activities have been carried out in a cost-effective 
     manner.
       ``(2) Alternatives to centers.--In carrying out the study 
     under paragraph (1), the Secretary shall determine the extent 
     to which the activities described in section 2742 can be 
     effectively carried out through means other than centers 
     under such section. The alternative means considered by the 
     Secretary under the preceding sentence shall include the 
     alternative of requiring public and private health plans to 
     carry out such activities.
       ``(3) Date certain for completion.--Not later than November 
     1, 1996, the Secretary shall submit to the Congress a report 
     describing the findings made in the study under paragraph 
     (1).
       ``(4) Notice to centers.--Not later than February 1, 1997, 
     the Secretary shall notify each grantee under section 2742 
     whether the Secretary considers the continued operation of 
     the center involved to be necessary in meeting the needs of 
     the geographic region involved for the activities described 
     in such section.
              ``Subtitle D--School-Related Health Services

     ``SEC. 2746. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

       ``(a) Funding for School-Related Health Services.--For the 
     purpose of carrying out this subtitle, there are authorized 
     to be appropriated from the Fund, $100,000,000 for fiscal 
     year 1996, $200,000,000 for fiscal year 1997, $300,000,000 
     for fiscal year 1998, $400,000,000 for fiscal year 1999, and 
     $500,000,000 for fiscal year 2000.
       ``(b) Funding for Planning and Development Grants.--Of 
     amounts made available under this section, not to exceed 
     $10,000,000 for each of fiscal years 1996 and 1997 may be 
     utilized to carry out section 2749.

     ``SEC. 2747. ELIGIBILITY FOR GRANTS.

       ``(a) In General.--
       ``(1) Planning and development grants.--Entities eligible 
     to apply for and receive grants under section 2749 are--
       ``(A) State health agencies that apply on behalf of local 
     community partnerships; or
       ``(B) local community partnerships in States in which 
     health agencies have not successfully applied.
       ``(2) Operational grants.--Entities eligible to apply for 
     and receive grants under section 2750 are--
       ``(A) a qualified State as designated under subsection (c) 
     that apply on behalf of local community partnerships; or
       ``(B) local community partnerships in States that are not 
     designated under subparagraph (A).
       ``(b) Local Community Partnerships.--
       ``(1) In general.--A local community partnership under 
     subsection (a)(1)(B) and (a)(2)(B) is an entity that, at a 
     minimum includes--
       ``(A) a local health care provider, which may be a local 
     public health department, with experience in delivering 
     services to children and youth or medically underserved 
     populations;
       ``(B) local educational agency on behalf of one or more 
     public schools; and
       ``(C) one community based organization located in the 
     community to be served that has a history of providing 
     services to at-risk children and youth.
       ``(2) Rural communities.--In rural communities, local 
     partnerships should seek to include, to the fullest extent 
     practicable, providers and community based organizations with 
     experience in serving the target population.
       ``(3) Parent and community participation.--An applicant 
     described in subsection (a) shall, to the maximum extent 
     feasible, involve broad-based community participation 
     (including parents of the youth to be served).
       ``(c) Qualified State.--A qualified State under subsection 
     (a)(2)(A) is a State that, at a minimum--
       ``(1) demonstrates an organizational commitment (including 
     a strategic plan) to providing a broad range of health, 
     health education and support services to at-risk youth; and
       ``(2) has a memorandum of understanding or cooperative 
     agreement jointly entered into by the State agencies 
     responsible for health and education regarding the planned 
     delivery of health and support services in school-based or 
     school-linked centers.

     ``SEC. 2748. PREFERENCES.

       ``In making grants under sections 2749 and 2750, the 
     Secretary shall give priority to applicants whose-communities 
     to be served show the most substantial level of need for 
     health services among children and youth.

     ``SEC. 2749. PLANNING AND DEVELOPMENT GRANTS.

       ``(a) In General.--The Secretary may make grants during 
     fiscal years 1996 and 1997 to entities eligible under section 
     2747 to develop school-based or school-linked health service 
     sites.
       ``(b) Use of Funds.--Amounts provided under a grant under 
     this section may be used for the following:
       ``(1) Planning for the provision of school health services, 
     including--
       ``(A) an assessment of the need for health services among 
     youth in the communities to be served;
       ``(B) the health services to be provided and how new 
     services will be integrated with existing services;
       ``(C) assessing and planning for the modernization and 
     expansion of existing facilities and equipment to accommodate 
     such services; and
       ``(D) an affiliation with relevant health plans.
       ``(2) Recruitment and training of staff for the 
     administration and delivery of school health services.
       ``(3) The establishment of local community partnerships as 
     described in section 2747(b).
       ``(4) In the case of States, the development of memorandums 
     of understanding or cooperative agreements for the 
     coordinated delivery of health and support services through 
     school health service sites.
       ``(5) Other activities necessary to assume operational 
     status.
       ``(c) Application for Grants.--To be eligible to receive a 
     grant under this section an entity described in section 
     2747(a) shall submit an application in a form and manner 
     prescribed by the Secretary.
       ``(d) Number of Grants.--Not more than one planning grant 
     may be made to a single applicant. A planning grant may not 
     exceed 2 years in duration.
       ``(e) Amount Available for Development Grant.--The 
     Secretary may award not to exceed--
       ``(1) $150,000 to entities under section 2747(a)(1)(A) and 
     to localities planning for a citywide or countywide school 
     health services delivery system; and
       ``(2) $50,000 to entities under section 2747(a)(1)(B).

     ``SEC. 2759. GRANTS FOR OPERATION OF SCHOOL HEALTH SERVICES.

       ``(a) In General.--The Secretary may make grants to 
     eligible entities described in section 2747(a)(2) that submit 
     applications consistent with the requirements of this 
     section, to pay the cost of operating school-based or school-
     linked health service sites.
       ``(b) Use of Grant.--Amounts provided under a grant under 
     this section may be used for the following--
       ``(1) health services, including diagnosis and treatment of 
     simple illnesses and minor injuries;
       ``(2) preventive health services, including health 
     screenings follow-up health care, mental health, and 
     preventive health education;
       ``(3) enabling services and other necessary support 
     services;
       ``(4) training, recruitment, and compensation of health 
     professionals and other staff necessary for the 
     administration and delivery of school health services; and
       ``(5) referral services, including the linkage of 
     individuals to health plans, and community-based health and 
     social service providers.
       ``(c) Application for Grant.--To be eligible to receive a 
     grant under this section an entity described in section 
     2747(a)(2) shall submit an application in a form and manner 
     prescribed by the Secretary. In order to receive a grant 
     under this section, an applicant must include in the 
     application the following information--
       ``(1) a description of the services to be furnished by the 
     applicant;
       ``(2) the amounts and sources of funding that the applicant 
     will expend, including estimates of the amount of payments 
     the applicant will receive from health plans and other 
     sources;
       ``(3) a description of local community partnerships, 
     including parent and community participation;
       ``(4) a description of the linkages with other health and 
     social service providers; and
       ``(5) such other information as the Secretary determines to 
     be appropriate.
       ``(d) Assurances.--In order to receive a grant under this 
     section, an applicant must meet the following conditions--
       ``(1) school health service sites will, directly or 
     indirectly, provide a broad range of health services, in 
     accordance with the determinations of the local community 
     partnership, that may include--
       ``(A) diagnosis and treatment of simple illnesses and minor 
     injuries;
       ``(B) preventive health services, including health 
     screenings and follow-up health care, mental health and 
     preventive health education;
       ``(C) enabling services; and
       ``(D) referrals (including referrals regarding mental 
     health and substance abuse) with follow-up to ensure that 
     needed services are received;
       ``(2) the applicant provides services recommended by the 
     health provider, in consultation with the local community 
     partnership, and with the approval of the local education 
     agency;
       ``(3) the applicant provides the services under this 
     subsection to adolescents, and other school age children and 
     their families as deemed appropriate by the local 
     partnership;
       ``(4) the applicant maintains agreements with community-
     based health care providers with a history of providing 
     services to such populations for the provision of health care 
     services not otherwise provided directly or during the hours 
     when school health services are unavailable;
       ``(5) the applicant establishes an affiliation with 
     relevant health plans and will establish reimbursement 
     procedures and will make every reasonable effort to collect 
     appropriate reimbursement for services provided;
       ``(6) the applicant agrees to supplement and not supplant 
     the level of State or local funds under the direct control of 
     the applying State or participating local education or health 
     authority expended for school health services as defined by 
     this Act;
       ``(7) services funded under this Act will be coordinated 
     with existing school health services provided at a 
     participating school; and
       ``(8) for applicants in rural areas, the assurances 
     required under paragraph (4) shall be fulfilled to the 
     maximum extent possible.
       ``(e) State Laws.--Notwithstanding any other provision in 
     this subtitle, no school based health clinic may provide 
     services, to any minor, when to do so is a violation of State 
     laws or regulations pertaining to informed consent for 
     medical services to minors.
       ``(f) Limitation on Administrative Funds.--In the case of a 
     State applying on behalf of local educational partnerships, 
     the applicant may retain not more than 5 percent of grants 
     awarded under this subpart for administrative costs.
       ``(g) Duration of Grant.--A grant under this section shall 
     be for a period determined appropriate by the Secretary.
       ``(h) Amount of Grant.--The annual amount of a grant 
     awarded under this section shall not be more than $200,000 
     per school-based or school-linked health service site.
       ``(i) Federal Share.--
       ``(1) In general.--Subject to paragraph (3), a grant for 
     services awarded under this section may not exceed--
       ``(A) 90 percent of the non-reimbursed cost of the 
     activities to be funded under the program for the first 2 
     fiscal years for which the program receives assistance under 
     this section; and
       ``(B) 75 percent of the non-reimbursed cost of such 
     activities for subsequent years for which the program 
     receives assistance under this section.

     The remainder of such costs shall be made available as 
     provided in paragraph (2).
       ``(2) Form of non-federal share.--The non-Federal share 
     required by paragraph (1) may be in cash or in-kind, fairly 
     evaluated, including facilities, equipment, personnel, or 
     services, but may not include amounts provided by the Federal 
     Government. In-kind contributions may include space within 
     school facilities, school personnel, program use of school 
     transportation systems, outposted health personnel, and 
     extension of health provider medical liability insurance.
       ``(3) Waiver.--The Secretary may waive the requirements of 
     paragraph (1) for any year in accordance with criteria 
     established by regulation. Such criteria shall include a 
     documented need for the services provided under this section 
     and an inability of the grantee to meet the requirements of 
     paragraph (1) despite a good faith effort.
       ``(j) Training and Technical Assistance.--Entities that 
     receive assistance under this section may use not to exceed 
     10 percent of the amount of such assistance to provide staff 
     training and to secure necessary technical assistance. To the 
     maximum extent feasible, technical assistance should be 
     sought through local community-based entities. The limitation 
     contained in this subsection shall apply to individuals 
     employed to assist in obtaining funds under this subtitle. 
     Staff training should include the training of teachers and 
     other school personnel necessary to ensure appropriate 
     referral and utilization of services, and appropriate 
     linkages between class-room activities and services offered.
       ``(k) Report and Monitoring.--The Secretary will submit to 
     the Committee on Labor and Human Resources in the Senate and 
     the Committee on Energy and Commerce in the House of 
     Representatives a biennial report on the activities funded 
     under this Act, consistent with the ongoing monitoring 
     activities of the Department. Such reports are intended to 
     advise the relevant Committees of the availability and 
     utilization of services, and other relevant information about 
     program activities.
``Subtitle E--Expansion of Rural and Underserved Areas Access to Health 
                                Services

             ``PART 1--COMMUNITY AND MIGRANT HEALTH CENTERS

     ``SEC. 2756. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``(a) In General.--For the purpose of carrying out this 
     part, there is authorized to be appropriated from the Fund, 
     $100,000,000 for each of the fiscal years 1996 through 2000.
       ``(b) Relation to Other Funds.--The authorizations of 
     appropriations established in subsection (a) for the purpose 
     described in such subsection are in addition to any other 
     authorizations of appropriations that are available for such 
     purpose.

     ``SEC. 2757. GRANTS TO COMMUNITY AND MIGRANT HEALTH CENTERS.

       ``(a) In General.--The Secretary shall make grants in 
     accordance with this section to migrant health centers and 
     community health centers.
       ``(b) Use of Funds.--
       ``(1) Development, operation, and other purposes regarding 
     centers.--Subject to paragraph (2), grants under subsection 
     (a) to migrant health centers and community health centers 
     may be made only in accordance with the conditions upon which 
     grants are made under sections 329 and 330, respectively.
       ``(2) Required financial reserves.--The Secretary may 
     authorize migrant health centers and community health centers 
     to expend a grant under subsection (a) to establish and 
     maintain financial reserves required for purposes of health 
     plans.
       ``(c) Definitions.--For purposes of this subtitle, the 
     terms `migrant health center' and `community health center' 
     have the meanings given such terms in sections 329(a)(1) and 
     330(a), respectively.

                ``PART 2--NATIONAL HEALTH SERVICE CORPS

     ``SEC. 2781. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

       ``(a) Additional Funding; General Corps Program; 
     Allocations Regarding Nurses.--For the purpose of carrying 
     out subpart II of part D of title III, and for the purpose of 
     carrying out subsection (c), there are authorized to be 
     appropriated from the Fund, $100,000,000 for each of the 
     fiscal years 1996 through 2000.
       ``(b) Relation to Other Funds.--The authorizations of 
     appropriations established in subsection (a) are in addition 
     to any other authorizations of appropriations that are 
     available for the purpose described in such subsection.
       ``(c) Allocation for Participation of Nurses in Scholarship 
     and Loan Repayment Programs.--Of the amounts appropriated 
     under subsection (a), the Secretary shall reserve such 
     amounts as may be necessary to ensure that, of the aggregate 
     number of individuals who are participants in the Scholarship 
     Program under section 338A, or in the Loan Repayment Program 
     under section 338B, the total number who are being educated 
     as nurses or are serving as nurses, respectively, is 
     increased to 30 percent.
       ``(d) Availability of Funds.--An appropriation under this 
     section for any fiscal year may be made at any time before 
     that fiscal year and may be included in an Act making an 
     appropriation under an authorization under subsection (a) for 
     another fiscal year; but no funds may be made available from 
     any appropriation under this section for obligation under 
     sections 331 through 335, section 336A, and section 337 
     before the fiscal year involved.

       ``PART 3--SATELLITE CLINICS REGARDING PRIMARY HEALTH CARE

     ``SEC. 2783. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this part, there is 
     authorized to be appropriated from the Fund, $50,000,000 for 
     each of the fiscal years 1996 through 2000.

     ``SEC. 2783A. GRANTS TO STATES FOR DEVELOPMENT AND OPERATION 
                   OF SATELLITE CLINICS.

       ``(a) In General.--With respect to outpatient health 
     centers that are providers of comprehensive health services, 
     the Secretary may make grants to States for the purpose of 
     assisting such centers in developing or operating facilities 
     that--
       ``(1) provide clinical preventive services, treatment of 
     minor illnesses and injuries, family planning services, and 
     referrals for health services, mental health services, and 
     health-related social services; and
       ``(2) are located at a distance from the center sufficient 
     to increase the extent to which individuals in the geographic 
     area involved have access to the services specified in 
     paragraph (1).
       ``(b) Certain Requirements.--The Secretary may make a grant 
     under subsection (a) only if the State agrees that the health 
     facility for which the grant is made, once in operation, will 
     meet the following conditions:
       ``(1) The clinical preventive services provided by the 
     facility will include routine preventive services, including 
     family planning services, for pregnant and postpartum women 
     and for children, including health screenings and 
     immunizations.
       ``(2) The principal providers of health services at the 
     facility, and the principal managers of the facility, will be 
     nurse practitioners, physician assistants, or nurse 
     clinicians, subject to applicable law.
       ``(3) The outpatient health center operating the facility 
     will serve as a referral center for physician services and 
     will provide for the ongoing monitoring of the activities of 
     the facility.
       ``(c) Matching Funds.--The Secretary may make a grant under 
     subsection (a) only if the State involved agrees to make non-
     Federal contributions toward the costs of developing and 
     operating the health facilities involved.
       ``(d) Application for Grant.--The Secretary may make a 
     grant under subsection (a) only if an application for the 
     grant is submitted to the Secretary and the application is in 
     such form, is made in such manner, and contains such 
     agreements, assurances, and information as the Secretary 
     determines to be necessary to carry out this part.
       ``(e) Limitation on Amount of Assistance Per Facility.--
     With respect to a health facility for which one or more 
     grants under subsection (a) are made, the Secretary may not 
     provide more than an aggregate $250,000 for the development 
     and operation of the facility.

                  ``PART 4--COMMUNITY HEALTH ADVISORS

     ``SEC. 2784. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

       ``For the purpose of carrying out this part, there is 
     authorized to be appropriated from the Fund, $100,000,000 for 
     each of the fiscal years 1996 through 2000.

     ``SEC. 2785. FORMULA GRANTS REGARDING COMMUNITY HEALTH 
                   ADVISOR PROGRAMS.

       ``(a) Formula Grants.--
       ``(1) In general.--In the case of each State (or entity 
     designated by a State under subsection (b)) that submits to 
     the Secretary an application in accordance with section 2788 
     for a fiscal year, the Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention and in coordination with the 
     heads of the agencies specified in paragraph (2), shall make 
     an award of financial assistance to the State or entity for 
     the development and operation of community health advisor 
     programs under section 2786(b). The award shall consist of 
     the allotment determined under section 2789 with respect to 
     the State, subject to section 2794.
       ``(2) Coordination with other agencies.--The agencies 
     referred to in paragraph (1) regarding coordination are the 
     Health Resources and Services Administration, the National 
     Institutes of Health, the Substance Abuse and Mental Health 
     Services Administration, and the Health Education and 
     Training Center.
       ``(b) Designated Entities.--With respect to the State 
     involved, an entity other than the State may receive an award 
     under subsection (a) only if the entity--
       ``(1) is a public or nonprofit private academic 
     organization (or other public or nonprofit private entity); 
     and
       ``(2) has been designated by the State to carry out the 
     purpose described in such subsection in the State and to 
     receive amounts under such subsection in lieu of the State.
       ``(c) Role of State Agency for Public Health.--A funding 
     agreement for an award under subsection (a) is that--
       ``(1) if the applicant is a State, the award will be 
     administered by the State agency with the principal 
     responsibility for carrying out public health programs; and
       ``(2) if the applicant is an entity designated under 
     subsection (b), the award will be administered in 
     consultation with such State agency.
       ``(d) Statewide Responsibilities; Limitation on 
     Expenditures.--
       ``(1) Statewide responsibilities.--A funding agreement for 
     an award under subsection (a) is that the applicant involved 
     will--
       ``(A) operate a clearinghouse to maintain and disseminate 
     information on community health advisor programs (and similar 
     programs) in the State, including information on developing 
     and operating such programs, on training individuals to 
     participate in the programs, and on evaluation of the 
     programs;
       ``(B) collaborate with schools of public health to provide 
     to community health advisor programs in the State technical 
     assistance in training and supervising community health 
     advisors under section 2787(g)(1); and
       ``(C) coordinate the activities carried out in the State 
     under the award, including coordination between the various 
     community health advisor programs and coordination between 
     such programs and related activities of the State and of 
     other public or private entities.
       ``(2) Limitation.--A funding agreement for an award under 
     subsection (a) is that the applicant involved will not expend 
     more than 15 percent of the award in the aggregate for 
     carrying out paragraph (1) and for the expenses of 
     administering the award with respect to the State involved, 
     including the process of receiving payments from the 
     Secretary under the award, allocating the payments among the 
     entities that are to develop and operate the community health 
     advisor programs involved, and monitoring compliance with the 
     funding agreements made under this subtitle by the applicant.

     ``SEC. 2786. REQUIREMENTS REGARDING COMMUNITY HEALTH ADVISOR 
                   PROGRAMS.

       ``(a) Purpose of Award; Healthy People 2000 Objectives.--
       ``(1) In general.--Subject to paragraph (2), a funding 
     agreement for an award under section 2785 for an applicant is 
     that the purpose of the award is, through community health 
     advisor programs under subsection (b), to assist the State 
     involved in attaining the Healthy People 2000 Objectives.
       ``(2) Authority regarding selection of priority 
     objectives.--With respect to compliance with the agreement 
     made under paragraph (1), an applicant receiving an award 
     under section 2785 may, from among the various Healthy People 
     2000 Objectives, select one or more Objectives to be given 
     priority in the operation of a community health advisor 
     program of the applicant, subject to the applicant selecting 
     such priorities in consultation with the entity that is to 
     carry out the program and the local health department 
     involved.
       ``(b) Requirements for Programs.--
       ``(1) In general.--A funding agreement for an award under 
     section 2785 for an applicant is that, in expending the 
     award, the purpose described in subsection (a)(1) will be 
     carried out in accordance with the following:
       ``(A) For each community for which the purpose is to be 
     carried out, the applicant will establish a program in 
     accordance with this subsection.
       ``(B) The program will be carried out in a community only 
     if the applicant has, under section 2787(a), identified the 
     community as having a significant need for the program.
       ``(C) The program will be operated by a public or nonprofit 
     private entity with experience in providing health or health-
     related social services to individuals who are underserved 
     with respect to such services.
       ``(D) The services of the program, as specified in 
     paragraph (2), will be provided principally by community 
     health advisors (as defined in subsection (d)).
       ``(2) Authorized program services.--For purposes of 
     paragraph (1)(D), the services specified in this paragraph 
     for a program are as follows:
       ``(A) The program will collaborate with health care 
     providers and related entities in order to facilitate the 
     provision of health services and health-related social 
     services (including collaborating with local health 
     departments, community health centers, public hospital 
     systems, migrant health centers, rural health clinics, 
     hospitals, physicians and nurses, providers of health 
     education, pre-school facilities for children, elementary and 
     secondary schools, and providers of social services).
       ``(B) The program will provide public education on health 
     promotion and on the prevention of diseases, illnesses, 
     injuries, and disabilities, and will facilitate the 
     appropriate use of available health services and health-
     related social services.
       ``(C) The program will provide health-related counseling.
       ``(D) The program will provide referrals for available 
     health services and health-related social services.
       ``(E) For the purpose of increasing the capacity of 
     individuals to utilize health services and health-related 
     social services under Federal, State, and local programs, the 
     following conditions will be met:
       ``(i) The program will assist individuals in establishing 
     eligibility under the programs and in receiving the services 
     or other benefits of the programs.
       ``(ii) The program will provide such other services as the 
     Secretary determines to be appropriate, which services may 
     include (but are not limited to) transportation and 
     translation services.
       ``(F) The program will provide outreach services to inform 
     the community of the availability of the services of the 
     program.
       ``(c) Priority for Medically Underserved Communities.--A 
     funding agreement for an award under section 2785 is that the 
     applicant involved will give priority to developing and 
     operating community health advisor programs for medically 
     underserved communities.
       ``(d) Definition of Community Health Advisor.--For purposes 
     of this part, the term `community health advisor' means an 
     individual--
       ``(1) who has demonstrated the capacity to carry out one or 
     more of the authorized program services;
       ``(2) who, for not less than 1 year, has been a resident of 
     the community in which the community health advisor program 
     involved is to be operated; and
       ``(3) is a member of a socioeconomic group to be served by 
     the program.

     ``SEC. 2787. ADDITIONAL AGREEMENTS.

       ``(a) Identification of Community Needs.--A funding 
     agreement for an award under section 2785 is that the 
     applicant involved will--
       ``(1) identify the needs of the community involved for the 
     authorized program services, including the identifying the 
     resources of the community that are available for carrying 
     out the program;
       ``(2) in identifying such needs, consult with members of 
     the community, with individuals and programs that provide 
     health services in the community, and with individuals and 
     programs that provide health-related social services in the 
     community; and
       ``(3) consider such needs in carrying out a community 
     health advisor program for the community.
       ``(b) Matching Funds.--
       ``(1) In general.--With respect to the cost of carrying out 
     a community health advisor program, a funding agreement for 
     an award under section 2785 is that the applicant involved 
     will make available (directly or through donations from 
     public or private entities) non-Federal contributions toward 
     such cost in an amount that is not less than 25 percent of 
     such cost.
       ``(2) Determination of amount contributed.--
       ``(A) Non-Federal contributions required in paragraph (1) 
     may be in cash or in kind, fairly evaluated, including plant, 
     equipment, or services. Amounts provided by the Federal 
     Government, or services assisted or subsidized to any 
     significant extent by the Federal Government, may not be 
     included in determining the amount of such non-Federal 
     contributions.
       ``(B) With respect to the State in which the community 
     health advisor program involved is to be carried out, amounts 
     provided by the State in compliance with subsection (c) shall 
     be included in determining the amount of non-Federal 
     contributions under paragraph (1).
       ``(c) Maintenance of Effort.--With respect to the purposes 
     for which an award under section 2785 is authorized in this 
     subtitle to be expended, the Secretary may make such an award 
     only if the State involved agrees to maintain expenditures of 
     non-Federal amounts for such purposes at a level that is not 
     less than the level of such expenditures maintained by the 
     State for the fiscal year preceding the first fiscal year for 
     which such an award is made with respect to the State.
       ``(d) Cultural Context of Services.--A funding agreement 
     for an award under section 2785 for an applicant is that the 
     services of the community health advisor program involved 
     will be provided in the language and cultural context most 
     appropriate for the individuals served by the program, and 
     that for such purpose the community health advisors of the 
     program will include an appropriate number of advisors who 
     are fluent in both English and not less than one of the other 
     relevant languages.
       ``(e) Number of Programs Per Award; Programs for Urban and 
     Rural Areas.--A funding agreement for an award under section 
     2785 for an applicant is that the number of community health 
     advisor programs operated in the State with the award will be 
     determined by the Secretary, except that (subject to section 
     2786(b)(1)(B)) such a program will be carried out in not less 
     than one urban area of the State, and in not less than one 
     rural area of the State.
       ``(f) Ongoing Supervision of Advisors.--A funding agreement 
     for an award under section 2785 is that the applicant 
     involved will ensure that each community health advisor 
     program operated with the award provides for the ongoing 
     supervision of the community health advisors of the program, 
     and that the individuals serving as supervisors in the 
     program will include 1 or more public health nurses with 
     field experience and managerial experience.
       ``(g) Certain Expenditures.--
       ``(1) Training; continuing education.--Funding agreements 
     for an award under section 2785 include the following:
       ``(A) The applicant involved will ensure that, for each 
     community health advisor program operated with the award, a 
     program is carried out to train community health advisors to 
     provide the authorized program services, including practical 
     experiences in providing services for health promotion and 
     disease prevention.
       ``(B) The program of training will provide for the 
     continuing education of the community health advisors.
       ``(C) Not more than 15 percent of the award will be 
     expended for the program of training.
       ``(2) Compensation.--With respect to compliance with the 
     agreements made under this subtitle, the purposes for which 
     an award under section 2785 may be expended include providing 
     compensation for the services of community health advisors.
       ``(h) Reports to Secretary; Assessment of Effectiveness.--
     Funding agreements for an award under section 2785 for an 
     applicant include the following:
       ``(1) The applicant will ensure that, for each fiscal year 
     for which a community health advisor program receives amounts 
     from the award, the program will prepare a report describing 
     the activities of the program for such year, including--
       ``(A) a specification of the number of individuals served 
     by the program;
       ``(B) a specification of the entities with which the 
     program has collaborated in carrying out the purpose 
     described in section 2786(a)(1); and
       ``(C) an assessment of the extent of the effectiveness of 
     the program in carrying out such purpose.
       ``(2) Such reports will include such additional information 
     regarding the applicant and the programs as the Secretary may 
     require.
       ``(3) The applicant will prepare the reports as a single 
     document and will submit the document to the Secretary not 
     later than February 1 of the fiscal year following the fiscal 
     year for which the reports were prepared.

     ``SEC. 2788. APPLICATION FOR ASSISTANCE; STATE PLAN.

       ``For purposes of section 2785, an application is in 
     accordance with this section if--
       ``(1) the application is submitted not later than the date 
     specified by the Secretary;
       ``(2) the application contains each funding agreement 
     described in this subtitle;
       ``(3) the application contains a State plan describing the 
     purposes for which the award is to be expended in the State, 
     including a description of the manner in which the applicant 
     will comply with each such funding agreement; and
       ``(4) the application is in such form, is made in such 
     manner, and contains such agreements, assurances, and 
     information as the Secretary determines to be necessary to 
     carry out this subtitle.

     ``SEC. 2789. DETERMINATION OF AMOUNT OF ALLOTMENT.

       ``(a) In General.--For purposes of section 2785, the 
     allotment under this section with respect to a State for a 
     fiscal year is the sum of the respective amounts determined 
     for the State under subsection (b) and subsection (c).
       ``(b) Amount Relating to Population.--For purposes of 
     subsection (a), the amount determined under this subsection 
     is the product of--
       ``(1) an amount equal to 50 percent of the amount 
     appropriated under section 2784 for the fiscal year and 
     available for awards under section 2785; and
       ``(2) the percentage constituted by the ratio of--
       ``(A) the number of individuals residing in the State 
     involved; to
       ``(B) the sum of the respective amounts determined for each 
     State under subparagraph (A).
       ``(c) Amount Relating to Poverty Level.--For purposes of 
     subsection (a), the amount determined under this subsection 
     is the product of--
       ``(1) the amount determined under subsection (b)(1); and
       ``(2) the percentage constituted by the ratio of--
       ``(A) the number of individuals residing in the State whose 
     income is at or below an amount equal to 200 percent of the 
     official poverty line; to
       ``(B) the sum of the respective amounts determined for each 
     State under subparagraph (A).

     ``SEC. 2790. QUALITY ASSURANCE; COST-EFFECTIVENESS.

       ``The Secretary shall establish guidelines for assuring the 
     quality of community health advisor programs (including 
     quality in the training of community health advisors) and for 
     assuring the cost-effectiveness of the programs. A funding 
     agreement for an award under section 2785 is that the 
     applicant involved will carry out such programs in accordance 
     with the guidelines.

     ``SEC. 2791. EVALUATIONS; TECHNICAL ASSISTANCE.

       ``(a) Evaluations.--The Secretary shall conduct evaluations 
     of community health advisor programs and disseminate 
     information developed as result of the evaluations to the 
     States. In conducting such evaluations, the Secretary shall 
     determine whether the programs are in compliance with the 
     guidelines established under section 2790.
       ``(b) Technical Assistance.--The Secretary may provide 
     technical assistance to recipients of awards under section 
     2785 with respect to the planning, development, and operation 
     of community health advisor programs.
       ``(c) Grants and Contracts.--The Secretary may carry out 
     this section directly or through grants, cooperative 
     agreements, or contracts.
       ``(d) Limitation on Expenditures.--Of the amounts 
     appropriated under section 2784 for a fiscal year, the 
     Secretary may reserve not more than 10 percent for carrying 
     out this section.

     ``SEC. 2792. RULE OF CONSTRUCTION REGARDING PROGRAMS OF 
                   INDIAN HEALTH SERVICE.

       ``This subtitle may not be construed as requiring the 
     Secretary to modify or terminate the program carried out by 
     the Director of the Indian Health Service and designated by 
     such Director as the Community Health Representative Program. 
     The Secretary shall ensure that support for such Program is 
     not supplanted by awards under section 2785. In communities 
     in which both such Program and a community health advisor 
     program are being carried out, the Secretary shall ensure 
     that the community health advisor program works in 
     cooperation with, and as a complement to, the Community 
     Health Representative Program.

     ``SEC. 2793. DEFINITIONS.

       ``For purposes of this subtitle:
       ``(1) The term `authorized program services', with respect 
     to a community health advisor program, means the services 
     specified in section 2786(b)(2).
       ``(2) The term `community health advisor' has the meaning 
     given such term in section 2786(d).
       ``(3) The term `community health advisor program' means a 
     program carried out under section 2786(b).
       ``(4) The term `financial assistance', with respect to an 
     award under section 2785, means a grant, cooperative 
     agreement, or a contract.
       ``(5) The term `funding agreement' means an agreement 
     required as a condition of receiving an award under section 
     2785.
       ``(6) The term `official poverty line' means the official 
     poverty line established by the Director of the Office of 
     Management and Budget and revised by the Secretary in 
     accordance with section 673(2) of the Omnibus Budget 
     Reconciliation Act of 1981, which poverty line is applicable 
     the size of the family involved.
       ``(7) The term `State involved', with respect to an 
     applicant for an award under section 2785, means the State in 
     which the applicant is to carry out a community health 
     advisor program.

     ``SEC. 2794. EFFECT OF INSUFFICIENT APPROPRIATIONS FOR 
                   MINIMUM ALLOTMENTS.

       ``(a) In General.--If the amounts made available under 
     section 2784 for a fiscal year are insufficient for providing 
     each State (or entity designated by the State pursuant to 
     section 2785, as the case may be) with an award under section 
     2785 in an amount equal to or greater than the amount 
     specified in section 2789(a)(2), the Secretary shall, from 
     such amounts as are made available under subsection (a), make 
     such awards on a discretionary basis.
       ``(b) Rule of Construction.--For purposes of subsection 
     (a), awards under section 2785 are made on a discretionary 
     basis if the Secretary determines which States (or entities 
     designated by States pursuant to such section, as the case 
     may be) are to receive such awards, subject to meeting the 
     requirements of this subtitle for such an award, and the 
     Secretary determines the amount of such awards.
                    ``Subtitle F--General Provisions

     ``SEC. 2798. REQUIREMENT REGARDING ACCREDITATION OF SCHOOLS, 
                   DEPARTMENTS, AND PROGRAMS.

       ``Except as indicated otherwise in this title:
       ``(1) A reference in this title to a school of public 
     health, a school of nursing, or any other entity providing 
     education or training in a health profession (whether a 
     school, department, program, or other entity) is a reference 
     to the entity as defined under section 799 or 853.
       ``(2) If an entity is not defined in either of such 
     sections, the reference in this title to the entity has the 
     meaning provided by the Secretary, except that the Secretary 
     shall require for purposes of this title that the entity be 
     accredited for the provision of the education or training 
     involved.

     ``SEC. 2799. RELATION TO OTHER FUNDS.

       ``Notwithstanding any other provision of law, the 
     authorizations of appropriations established in this title 
     are in addition to any other authorizations of appropriations 
     that are available for the purposes described with respect to 
     such appropriations in this title.

     ``SEC. 2799A. DEFINITIONS.

       ``(a) In General.--For purposes of this title:
       ``(1) The term `Healthy People 2000 Objectives' means the 
     objectives established by the Secretary toward the goals of 
     increasing the span of healthy life, reducing health 
     disparities among various populations, and providing access 
     to preventive services, which objectives apply to the health 
     status of the population of the United States for the year 
     2000.
       ``(2) The term `medically underserved community' means--
       ``(A) a community that has a substantial number of 
     individuals who are members of a medically underserved 
     population, as defined in section 330; or
       ``(B) a community a significant portion of which is a 
     health professional shortage area designated under section 
     332.''.
                       TITLE IV--MEDICAL RESEARCH

     SEC. 4001. FINDINGS.

       The Congress finds the following:
       (1) Nearly 4 of 5 peer reviewed research projects deemed 
     worthy of funding by the National Institutes of Health are 
     not funded.
       (2) Less than 2 percent of the nearly one trillion dollars 
     our Nation spends on health care is devoted to health 
     research, while the defense industry spends 15 percent of its 
     budget on research.
       (3) Public opinion surveys have shown that Americans want 
     more Federal resources put into health research and support 
     by having a portion of their health insurance premiums set 
     aside for this purpose.
       (4) Ample evidence exists to demonstrate that health 
     research has improved the quality of health care in the 
     United States. Advances such as the development of vaccines, 
     the cure of many childhood cancers, drugs that effectively 
     treat a host of diseases and disorders, a process to protect 
     our Nation's blood supply from the HIV virus, progress 
     against cardiovasculor disease including heart attack and 
     stroke, and new strategies for the early detection and 
     treatment of diseases such as colon, breast, and prostate 
     cancer clearly demonstrates the benefits of health research.
       (5) Among the most effective methods to control health care 
     costs are prevention and cure of disease and disability, 
     thus, health research which holds the promise of cure and 
     prevention of disease and disability is a critical component 
     of any comprehensive health care reform plan.
       (6) The state of our Nation's research facilities at the 
     National Institutes of Health and at universities is 
     deteriorating significantly. Renovation and repair of these 
     facilities are badly needed to maintain and improve the 
     quality of research.
       (7) Because the Omnibus Budget Reconciliation Act of 1993 
     freezes discretionary spending for the next 5 years, the 
     Nation's investment in health research through the National 
     Institutes of Health is likely to decline in real terms 
     unless corrective legislative action is taken.
       (8) A health research fund is needed to maintain our 
     Nation's commitment to health research and to increase the 
     percentage of approved projects which receive funding at the 
     National Institutes of Health to at least 33 percent.

     SEC. 4002. NATIONAL FUND FOR HEALTH RESEARCH.

       (a) Establishment.--There is established in the Treasury of 
     the United States an account, to be known as the ``National 
     Fund for Health Research'' (hereafter referred to in this 
     section as the ``Fund''), consisting of such amounts as are 
     transferred to the Fund under subsection (b) and any interest 
     earned on investment of amounts in the Fund.
       (b) Transfers to Fund.--
       (1) In general.--With respect to each of the 5 full 
     calendar years beginning after the date of enactment of this 
     Act, the Secretary of the Treasury shall transfer to the Fund 
     an amount equal to the applicable amount under paragraph (2).
       (2) Applicable amount.--The applicable amount under this 
     paragraph is--
       (A) with respect to amounts in the Health Care Reform Trust 
     Fund established under section 9551(a)(2)(A) of the Internal 
     Revenue Code of 1986, $1,200,000,000 for each calendar year 
     described in paragraph (1); and
       (B) with respect to amounts received in the Treasury under 
     section 6097 of the Internal Revenue Code of 1986, 100 
     percent of the amounts received under such section in each 
     calendar year described in paragraph (1).
       (3) Designation of overpayments and contributions.--
       (A)  In general.--Subchapter A of chapter 61 of the 
     Internal Revenue Code of 1986 (relating to returns and 
     records) is amended by adding at the end the following new 
     part:

   ``PART IX--DESIGNATION OF OVERPAYMENTS AND CONTRIBUTIONS FOR THE 
                   NATIONAL FUND FOR HEALTH RESEARCH

``Sec. 6097. Amounts for the National Fund for Health Research.

     ``SEC. 6097. AMOUNTS FOR THE NATIONAL FUND FOR HEALTH 
                   RESEARCH.

       ``(a) In General.--Every individual (other than a 
     nonresident alien) may designate that--
       ``(1) a portion (not less than $1) of any overpayment of 
     the tax imposed by chapter 1 for the taxable year, and
       ``(2) a cash contribution (not less than $1),

     be paid over to the National Fund for Health Research 
     established under section 4002 of the Health Innovation 
     Partnership Act of 1994. In the case of a joint return of a 
     husband and wife, each spouse may designate one-half of any 
     such overpayment of tax (not less than $2).
       ``(b) Manner and Time of Designation.--Any designation 
     under subsection (a) may be made with respect to any taxable 
     year only at the time of filing the original return of the 
     tax imposed by chapter 1 for such taxable year. Such 
     designation shall be made either on the 1st page of the 
     return or on the page bearing the taxpayer's signature.
       ``(c) Overpayments Treated as Refunded.--For purposes of 
     this section, any overpayment of tax designated under 
     subsection (a) shall be treated as being refunded to the 
     taxpayer as of the last day prescribed for filing the return 
     of tax imposed by chapter 1 (determined with regard to 
     extensions) or, if later, the date the return is filed.
       ``(d) Designated Amounts Not Deductible.--No amount 
     designated pursuant to subsection (a) shall be allowed as a 
     deduction under section 170 or any other section for any 
     taxable year.
       ``(e) Termination.--This section shall not apply to taxable 
     years beginning in a calendar year after a determination by 
     the Secretary that the sum of all designations under 
     subsection (a) for taxable years beginning in the second and 
     third calendar years preceding the calendar year is less than 
     $5,000,000.''.
       (B) Clerical amendment.--The table of parts for subchapter 
     A of chapter 61 of such Code is amended by adding at the end 
     the following new item:

``Part IX. Designation of overpayments and contributions for the 
              National Fund for Health Research.''.

       (C) Effective date.--The amendments made by this paragraph 
     shall apply to taxable years beginning after December 31, 
     1994.
       (c) Expenditures From Fund.--
       (1) In general.--The Secretary of the Treasury shall pay 
     annually, within 30 days after the President signs an 
     appropriations Act for the Departments of Labor, Health and 
     Human Services, and Education and related agencies, or by the 
     end of the first quarter of the fiscal year, to the Secretary 
     of Health and Human Services on behalf of the National 
     Institutes of Health, an amount equal to the amount in the 
     National Fund for Health Research at the time of such 
     payment, to enable the Secretary to carry out the purpose of 
     section 404F of the Public Health Service Act, less any 
     administrative expenses which may be paid under paragraph 
     (3).
       (2) Purposes for expenditures from fund.--Part A of title 
     IV of the Public Health Service Act (42 U.S.C. 281 et seq.) 
     is amended by adding at the end the following new section:

     ``SEC. 404F. EXPENDITURES FROM THE NATIONAL FUND FOR HEALTH 
                   RESEARCH.

       ``(a) In General.--From amounts received for any fiscal 
     year from the National Fund for Health Research, the 
     Secretary of Health and Human Services shall distribute--
       ``(1) 2 percent of such amounts during any fiscal year to 
     the Office of the Director of the National Institutes of 
     Health to be allocated at the Director's discretion for the 
     following activities:
       ``(A) for carrying out the responsibilities of the Office 
     of the Director, National Institutes of Health, including the 
     Office of Research on Women's Health and the Office of 
     Research on Minority Health, the Office of the Alternative 
     Medicine and the Office of Rare Diseases Research; and
       ``(B) for construction and acquisition of equipment for or 
     facilities of or used by the National Institutes of Health;
       ``(2) 2 percent of such amounts for transfer to the 
     National Center for Research Resources to carry out section 
     1502 of the National Institutes of Health Revitalization Act 
     of 1993 concerning Biomedical and Behavioral Research 
     Facilities;
       ``(3) 1 percent of such amounts during any fiscal year for 
     carrying out section 301 and part D of title IV with respect 
     to health information communications; and
       ``(4) the remainder of such amounts during any fiscal year 
     to member institutes of the National Institutes of Health and 
     centers in the same proportion to the total amount received 
     under this section, as the amount of annual appropriations 
     under appropriations Acts for each member institute and 
     center for the fiscal year bears to the total amount of 
     appropriations under appropriations Acts for all member 
     institutes and centers of the National Institutes of Health 
     for the fiscal year.
       ``(b) Plans of Allocation.--The amounts transferred under 
     subsection (a) shall be allocated by the Director of NIH or 
     the various directors of the institutes and centers, as the 
     case may be, pursuant to allocation plans developed by the 
     various advisory councils to such directors, after 
     consultation with such directors.''.
       (3) Administrative expenses.--Amounts in the National Fund 
     for Health Research shall be available to pay the 
     administrative expenses of the Department of the Treasury 
     directly allocable to--
       (A) modifying the individual income tax return forms to 
     carry out section 6097 of the Internal Revenue Code of 1986;
       (B) carrying out this section with respect to such Fund; 
     and
       (C) processing amounts received under this section and 
     transferring such amounts to such Fund.
       (4) Trigger and release of fund monies.--No expenditures 
     shall be made pursuant to section 4002(c) during any fiscal 
     year in which the annual amount appropriated for the National 
     Institutes of Health is less than the amount so appropriated 
     for the prior fiscal year.
       (d) Budget Enforcement.--Amounts contained in the National 
     Fund for Health Research shall be excluded from, and shall 
     not be taken into account for purposes of, any budget 
     enforcement procedures under the Congressional Budget Act of 
     1974 or the Balanced Budget Emergency Deficit Control Act of 
     1985.
                      TITLE V--REVENUE PROVISIONS

     SEC. 5000. AMENDMENT OF 1986 CODE.

       Except as otherwise expressly provided, whenever in this 
     title an amendment or repeal is expressed in terms of an 
     amendment to, or repeal of, a section or other provision, the 
     reference shall be considered to be made to a section or 
     other provision of the Internal Revenue Code of 1986.
                    Subtitle A--Financing Provisions

              PART I--INCREASE IN TAX ON TOBACCO PRODUCTS

     SEC. 5001. INCREASE IN EXCISE TAXES ON TOBACCO PRODUCTS.

       (a) Cigarettes.--Subsection (b) of section 5701 is 
     amended--
       (1) by striking ``$12 per thousand ($10 per thousand on 
     cigarettes removed during 1991 or 1992)'' in paragraph (1) 
     and inserting ``$62 per thousand'', and
       (2) by striking ``$25.20 per thousand ($21 per thousand on 
     cigarettes removed during 1991 or 1992)'' in paragraph (2) 
     and inserting ``$130.20 per thousand''.
       (b) Cigars.--Subsection (a) of section 5701 is amended--
       (1) by striking ``$1.125 cents per thousand (93.75 cents 
     per thousand on cigars removed during 1991 or 1992)'' in 
     paragraph (1) and inserting ``$51.13 per thousand'', and
       (2) by striking ``equal to'' and all that follows in 
     paragraph (2) and inserting ``equal to 66 percent of the 
     price for which sold but not more than $155 per thousand.''
       (c) Cigarette Papers.--Subsection (c) of section 5701 is 
     amended by striking ``0.75 cent (0.625 cent on cigarette 
     papers removed during 1991 or 1992)'' and inserting ``3.88 
     cents''.
       (d) Cigarette Tubes.--Subsection (d) of section 5701 is 
     amended by striking ``1.5 cents (1.25 cents on cigarette 
     tubes removed during 1991 or 1992)'' and inserting ``7.76 
     cents''.
       (e) Smokeless Tobacco.--Subsection (e) of section 5701 is 
     amended--
       (1) by striking ``36 cents (30 cents on snuff removed 
     during 1991 or 1992)'' in paragraph (1) and inserting 
     ``$13.69'', and
       (2) by striking ``12 cents (10 cents on chewing tobacco 
     removed during 1991 or 1992)'' in paragraph (2) and inserting 
     ``$5.45''.
       (f) Pipe Tobacco.--Subsection (f) of section 5701 is 
     amended by striking ``67.5 cents (56.25 cents on pipe tobacco 
     removed during 1991 or 1992)'' and inserting ``$17.35''.
       (g) Application of Tax Increase to Puerto Rico.--Section 
     5701 is amended by adding at the end the following new 
     subsection:
       ``(h) Application to Taxes to Puerto Rico.--Notwithstanding 
     subsections (b) and (c) of section 7653 and any other 
     provision of law--
       ``(1) In general.--On tobacco products and cigarette papers 
     and tubes, manufactured or imported into the Commonwealth of 
     Puerto Rico, there is hereby imposed a tax at the rate equal 
     to the excess of--
       ``(A) the rate of tax applicable under this section to like 
     articles manufactured in the United States, over
       ``(B) the rate referred to in subparagraph (A) as in effect 
     on the day before the date of the enactment of the Health 
     Innovation Partnership Act of 1994.
       ``(2) Shipments to puerto rico from the united states.--
     Only the rates of tax in effect on the day before the date of 
     the enactment of this subsection shall be taken into account 
     in determining the amount of any exemption from, or credit or 
     drawback of, any tax imposed by this section on any article 
     shipped to the Commonwealth of Puerto Rico from the United 
     States.
       ``(3) Shipments from puerto rico to the united states.--The 
     rates of tax taken into account under section 7652(a) with 
     respect to tobacco products and cigarette papers and tubes 
     coming into the United States from the Commonwealth of Puerto 
     Rico shall be the rates of tax in effect on the day before 
     the date of the enactment of the Health Innovation 
     Partnership Act of 1994.
       ``(4) Disposition of revenues.--The provisions of section 
     7652(a)(3) shall not apply to any tax imposed by reason of 
     this subsection.''
       (h) Effective Date.--The amendments made by this section 
     shall apply to articles removed (as defined in section 
     5702(k) of the Internal Revenue Code of 1986, as amended by 
     this Act) after December 31, 1994.
       (i) Floor Stocks Taxes.--
       (1) Imposition of tax.--On tobacco products and cigarette 
     papers and tubes manufactured in or imported into the United 
     States or the Commonwealth of Puerto Rico which are removed 
     before any tax-increase date, and held on such date for sale 
     by any person, there is hereby imposed a tax in an amount 
     equal to the excess of--
       (A) the tax which would be imposed under section 5701 of 
     the Internal Revenue Code of 1986 on the article if the 
     article had been removed on such date, over
       (B) the prior tax (if any) imposed under section 5701 or 
     7652 of such Code on such article.
       (2) Authority to exempt cigarettes held in vending 
     machines.--To the extent provided in regulations prescribed 
     by the Secretary, no tax shall be imposed by paragraph (1) on 
     cigarettes held for retail sale on any tax-increase date, by 
     any person in any vending machine. If the Secretary provides 
     such a benefit with respect to any person, the Secretary may 
     reduce the $500 amount in paragraph (3) with respect to such 
     person.
       (3) Credit against tax.--Each person shall be allowed as a 
     credit against the taxes imposed by paragraph (1) an amount 
     equal to $500. Such credit shall not exceed the amount of 
     taxes imposed by paragraph (1) on each tax-increase date for 
     which such person is liable.
       (4) Liability for tax and method of payment.--
       (A) Liability for tax.--A person holding cigarettes on any 
     tax-increase date, to which any tax imposed by paragraph (1) 
     applies shall be liable for such tax.
       (B) Method of payment.--The tax imposed by paragraph (1) 
     shall be paid in such manner as the Secretary shall prescribe 
     by regulations.
       (C) Time for payment.--The tax imposed by paragraph (1) 
     shall be paid on or before the date which is 3 months after 
     the tax-increase date.
       (5) Articles in foreign trade zones.--Notwithstanding the 
     Act of June 18, 1934 (48 Stat. 998, 19 U.S.C. 81a) and any 
     other provision of law, any article which is located in a 
     foreign trade zone on any tax-increase date shall be subject 
     to the tax imposed by paragraph (1) if--
       (A) internal revenue taxes have been determined, or customs 
     duties liquidated, with respect to such article before such 
     date pursuant to a request made under the 1st proviso of 
     section 3(a) of such Act, or
       (B) such article is held on such date under the supervision 
     of a customs officer pursuant to the 2d proviso of such 
     section 3(a).
       (6) Definitions.--For purposes of this subsection--
       (A) In general.--Terms used in this subsection which are 
     also used in section 5702 of the Internal Revenue Code of 
     1986 shall have the respective meanings such terms have in 
     such section, as amended by this Act.
       (B) Secretary.--The term ``Secretary'' means the Secretary 
     of the Treasury or his delegate.
       (C) Tax-increase date.--The term ``tax-increase date'' 
     means January 1, 1995, and July 1, 1996.
       (7) Controlled groups.--Rules similar to the rules of 
     section 5061(e)(3) of such Code shall apply for purposes of 
     this subsection.
       (8) Other laws applicable.--All provisions of law, 
     including penalties, applicable with respect to the taxes 
     imposed by section 5701 of such Code shall, insofar as 
     applicable and not inconsistent with the provisions of this 
     subsection, apply to the floor stocks taxes imposed by 
     paragraph (1), to the same extent as if such taxes were 
     imposed by such section 5701. The Secretary may treat any 
     person who bore the ultimate burden of the tax imposed by 
     paragraph (1) as the person to whom a credit or refund under 
     such provisions may be allowed or made.

     SEC. 5002. MODIFICATIONS OF CERTAIN TOBACCO TAX PROVISIONS.

       (a) Exemption for Exported Tobacco Products and Cigarette 
     Papers and Tubes To Apply Only to Articles Marked for 
     Export.--
       (1) Subsection (b) of section 5704 is amended by adding at 
     the end the following new sentence: ``Tobacco products and 
     cigarette papers and tubes may not be transferred or removed 
     under this subsection unless such products or papers and 
     tubes bear such marks, labels, or notices as the Secretary 
     shall by regulations prescribe.''
       (2) Section 5761 is amended by redesignating subsections 
     (c) and (d) as subsections (d) and (e), respectively, and by 
     inserting after subsection (b) the following new subsection:
       ``(c) Sale of Tobacco Products and Cigarette Papers and 
     Tubes for Export.--Except as provided in subsections (b) and 
     (d) of section 5704--
       ``(1) every person who sells, relands, or receives within 
     the jurisdiction of the United States any tobacco products or 
     cigarette papers or tubes which have been labeled or shipped 
     for exportation under this chapter,
       ``(2) every person who sells or receives such relanded 
     tobacco products or cigarette papers or tubes, and
       ``(3) every person who aids or abets in such selling, 
     relanding, or receiving,

     shall, in addition to the tax and any other penalty provided 
     in this title, be liable for a penalty equal to the greater 
     of $1,000 or 5 times the amount of the tax imposed by this 
     chapter. All tobacco products and cigarette papers and tubes 
     relanded within the jurisdiction of the United States, and 
     all vessels, vehicles, and aircraft used in such relanding or 
     in removing such products, papers, and tubes from the place 
     where relanded, shall be forfeited to the United States.''.
       (3) Subsection (a) of section 5761 is amended by striking 
     ``subsection (b)'' and inserting ``subsection (b) or (c)''.
       (4) Subsection (d) of section 5761, as redesignated by 
     paragraph (2), is amended by striking ``The penalty imposed 
     by subsection (b)'' and inserting ``The penalties imposed by 
     subsections (b) and (c)''.
       (5)(A) Subpart F of chapter 52 is amended by adding at the 
     end the following new section:

     ``SEC. 5754. RESTRICTION ON IMPORTATION OF PREVIOUSLY 
                   EXPORTED TOBACCO PRODUCTS.

       ``(a) In General.--Tobacco products and cigarette papers 
     and tubes previously exported from the United States may be 
     imported or brought into the United States only as provided 
     in section 5704(d). For purposes of this section, section 
     5704(d), section 5761, and such other provisions as the 
     Secretary may specify by regulations, references to 
     exportation shall be treated as including a reference to 
     shipment to the Commonwealth of Puerto Rico.
       ``(b) Cross Reference.--
  ``For penalty for the sale of tobacco products and cigarette papers 
and tubes in the United States which are labeled for export, see 
section 5761(c).''.
       (B) The table of sections for subpart F of chapter 52 is 
     amended by adding at the end the following new item:

``Sec. 5754. Restriction on importation of previously exported tobacco 
              products.''.

       (b) Importers Required To Be Qualified.--
       (1) Sections 5712, 5713(a), 5721, 5722, 5762(a)(1), and 
     5763(b) and (c) are each amended by inserting ``or importer'' 
     after ``manufacturer''.
       (2) The heading of subsection (b) of section 5763 is 
     amended by inserting ``Qualified Importers,'' after 
     ``Manufacturers,''.
       (3) The heading for subchapter B of chapter 52 is amended 
     by inserting ``and Importers'' after ``Manufacturers''.
       (4) The item relating to subchapter B in the table of 
     subchapters for chapter 52 is amended by inserting ``and 
     importers'' after ``manufacturers''.
       (c) Repeal of Tax-Exempt Sales to Employees of Cigarette 
     Manufacturers.--
       (1) Subsection (a) of section 5704 is amended--
       (A) by striking ``Employee Use or'' in the heading, and
       (B) by striking ``for use or consumption by employees or'' 
     in the text.
       (2) Subsection (e) of section 5723 is amended by striking 
     ``for use or consumption by their employees, or for 
     experimental purposes'' and inserting ``for experimental 
     purposes''.
       (d) Repeal of Tax-Exempt Sales to United States.--
     Subsection (b) of section 5704 is amended by striking ``and 
     manufacturers may similarly remove such articles for use of 
     the United States;''.
       (e) Books of 25 or Fewer Cigarette Papers Subject to Tax.--
     Subsection (c) of section 5701 is amended by striking ``On 
     each book or set of cigarette papers containing more than 25 
     papers,'' and inserting ``On cigarette papers,''.
       (f) Storage of Tobacco Products.--Subsection (k) of section 
     5702 is amended by inserting ``under section 5704'' after 
     ``internal revenue bond''.
       (g) Authority To Prescribe Minimum Manufacturing Activity 
     Requirements.--Section 5712 is amended by striking ``or'' at 
     the end of paragraph (1), by redesignating paragraph (2) as 
     paragraph (3), and by inserting after paragraph (1) the 
     following new paragraph:
       ``(2) the activity proposed to be carried out at such 
     premises does not meet such minimum capacity or activity 
     requirements as the Secretary may prescribe, or''.
       (h) Special Rules Relating to Puerto Rico and the Virgin 
     Islands.--Section 7652 is amended by adding at the end the 
     following new subsection:
       ``(h) Limitation on Cover Over of Tax on Tobacco 
     Products.--For purposes of this section, with respect to 
     taxes imposed under section 5701 or this section on any 
     tobacco product or cigarette paper or tube, the amount 
     covered into the treasuries of Puerto Rico and the Virgin 
     Islands shall not exceed the rate of tax under section 5701 
     in effect on the article on the day before the date of the 
     enactment of the Health Innovation Partnership Act of 
     1994.''.
       (i) Effective Date.--The amendments made by this section 
     shall apply to articles removed (as defined in section 
     5702(k) of the Internal Revenue Code of 1986, as amended by 
     this Act) after December 31, 1994.

     SEC. 5003. IMPOSITION OF EXCISE TAX ON MANUFACTURE OR 
                   IMPORTATION OF ROLL-YOUR-OWN TOBACCO.

       (a) In General.--Section 5701 (relating to rate of tax), as 
     amended by section 701, is amended by redesignating 
     subsections (g) and (h) as subsections (h) and (i) and by 
     inserting after subsection (f) the following new subsection:
       ``(g) Roll-Your-Own Tobacco.--On roll-your-own tobacco, 
     manufactured in or imported into the United States, there 
     shall be imposed a tax of $17.35 per pound (and a 
     proportionate tax at the like rate on all fractional parts of 
     a pound).''.
       (b) Roll-Your-Own Tobacco.--Section 5702 (relating to 
     definitions) is amended by adding at the end the following 
     new subsection:
       ``(p) Roll-Your-Own Tobacco.--The term `roll-your-own 
     tobacco' means any tobacco which, because of its appearance, 
     type, packaging, or labeling, is suitable for use and likely 
     to be offered to, or purchased by, consumers as tobacco for 
     making cigarettes.''.
       (c) Technical Amendments.--
       (1) Subsection (c) of section 5702 is amended by striking 
     ``and pipe tobacco'' and inserting ``pipe tobacco, and roll-
     your-own tobacco''.
       (2) Subsection (d) of section 5702 is amended--
       (A) in the material preceding paragraph (1), by striking 
     ``or pipe tobacco'' and inserting ``pipe tobacco, or roll-
     your-own tobacco'', and
       (B) by striking paragraph (1) and inserting the following 
     new paragraph:
       ``(1) a person who produces cigars, cigarettes, smokeless 
     tobacco, pipe tobacco, or roll-your-own tobacco solely for 
     the person's own personal consumption or use, and''.
       (3) The chapter heading for chapter 52 is amended to read 
     as follows:

    ``CHAPTER 52--TOBACCO PRODUCTS AND CIGARETTE PAPERS AND TUBES''.

       (4) The table of chapters for subtitle E is amended by 
     striking the item relating to chapter 52 and inserting the 
     following new item:

``Chapter 52. Tobacco products and cigarette papers and tubes.''.

       (d) Effective Date.--
       (1) In general.--The amendments made by this section shall 
     apply to roll-your-own tobacco removed (as defined in section 
     5702(k) of the Internal Revenue Code of 1986, as amended by 
     this Act) after December 31, 1994.
       (2) Transitional rule.--Any person who--
       (A) on the date of the enactment of this Act is engaged in 
     business as a manufacturer of roll-your-own tobacco or as an 
     importer of tobacco products or cigarette papers and tubes, 
     and
       (B) before January 1, 1995, submits an application under 
     subchapter B of chapter 52 of such Code to engage in such 
     business,

     may, notwithstanding such subchapter B, continue to engage in 
     such business pending final action on such application. 
     Pending such final action, all provisions of such chapter 52 
     shall apply to such applicant in the same manner and to the 
     same extent as if such applicant were a holder of a permit 
     under such chapter 52 to engage in such business.
               Subtitle B--Health Care Reform Trust Fund

     SEC. 5101. ESTABLISHMENT OF GRADUATE MEDICAL EDUCATION AND 
                   ACADEMIC HEALTH CENTERS TRUST FUND.

       (a) In General.--Subchapter A of chapter 98 (relating to 
     establishment of trust funds) is amended by adding at the end 
     the following new part:

                   ``PART II--HEALTH CARE TRUST FUNDS

``Sec. 9551. Health Care Reform Trust Fund

     ``SEC. 9551. HEALTH CARE REFORM TRUST FUND.

       ``(a) Creation of Trust Fund.--There is established in the 
     Treasury of the United States a trust fund to be known as the 
     `Health Care Reform Trust Fund', consisting of such amounts 
     as may be appropriated or credited to the Health Care Reform 
     Trust Fund as provided in this section.
       ``(b) Transfers to the Trust Fund.--There are hereby 
     appropriated to the Health Care Reform Trust Fund amounts 
     received in the Treasury under section 5701 (relating to 
     taxes on tobacco products) to the extent attributable to the 
     increases in such taxes as the result of the enactment of 
     section 5001 of the Health Innovation Partnership Act of 
     1994.
       ``(c) Expenditures.--Amounts in the Health Care Reform 
     Trust Fund are appropriated as provided for in sections 1001 
     and 4002 of the Health Innovation Partnership Act of 1994, 
     and title XXVII of the Public Health Service Act, and to the 
     extent any such amount is not expended during any fiscal 
     year, such amount shall be available for such purpose for 
     subsequent fiscal years.
       ``(d) Other Rules.--
       ``(1) Insufficient funds.--If, for any fiscal year, the sum 
     of the amounts required to be allocated under subsection (c) 
     exceeds the amounts received in the Health Care Reform Trust 
     Fund, then each of such amounts required to be so allocated 
     shall be reduced to an amount which bears the same ratio to 
     such amount as the amounts received in the trust fund bear to 
     the amounts required to be so allocated (without regard to 
     this paragraph).
       ``(2) Allocation of excess funds and interest.--Amounts 
     received in the Health Care Reform Trust Fund in excess of 
     the amounts required to be allocated under subsection (c), 
     for any fiscal year shall be allocated ratably on the basis 
     of the amounts allocated for the fiscal year (without regard 
     to this paragraph).''.
       (b) Conforming Amendment.--Subchapter A of chapter 98 is 
     amended by inserting after the subchapter heading the 
     following new items:

``Part I.  General trust funds.
``Part II. Health care trust fund.

``PART I--GENERAL TRUST FUNDS''.

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