[Congressional Record Volume 142, Number 87 (Thursday, June 13, 1996)]
[Senate]
[Pages S6226-S6228]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. McCAIN (for himself, Mrs. Kassebaum, Mr. Murkowski, Mr. 
        Stevens and Mr. Simon):
  S. 1869. A bill to make certain technical corrections in the Indian 
Health Care Improvement Act, and for other purposes; to the Committee 
on Indian Affairs.


  THE INDIAN HEALTH CARE IMPROVEMENT TECHNICAL CORRECTIONS ACT OF 1996

  Mr. McCAIN. Mr. President, I rise today on behalf of myself and 
Senators Kassebaum, Murkowski, Stevens, and Simon to introduce 
legislation to make various technical amendments to the Indian Health 
Care Improvement Act.
  The bill we are introducing today will simply make technical changes 
to certain provisions of the act and extend the authorization for 
several Indian health care demonstration programs.
  Mr. President, the Congress passed the Indian Health Care Improvement 
Act in 1976 to raise the level of health care provided to American 
Indians and Alaska Native communities. While the health status of 
Indian people has generally improved since its enactment, it still lags 
far behind any other segment of our population. Health crises in every 
possible problem area continue to afflict many reservation communities 
at alarming rates. The mortality rate for diabetes exceeds the national 
average by 139 percent. American Indians are four times more likely to 
die from alcoholism than other Americans. The incidence rates for fetal 
alcohol syndrome among native Americans is six times the national 
average.
  The Indian Health Care Improvement Act was enacted to meet the 
fundamental trust obligation of the United States to ensure that 
comprehensive health care would be provided to American Indians and 
Alaska Natives as it is provided to all other Americans. The act was 
amended in 1992 to extend most of the authorized programs through the 
year 2000, at which time the Indian Health Service is required to 
report to Congress on the progress of meeting the health objectives 
outlined in the act. Until such time, we are seeking to make minor 
changes to certain provisions of the act to allow maximum flexibility 
in the delivery of health services to American Indians and Alaska 
Natives and to ensure that several important tribal programs can 
continue through the year 2000.
  First, the bill amends section 4(n), the Indian health scholarship 
and loan repayment fund, by modifying the definition of the term 
``Health Profession.'' This modification will provide greater 
flexibility to the IHS to determine eligibility for financial 
assistance to Indians enrolled in health degree programs. Second, the 
bill amends section 104(b), the Indian health professions scholarship, 
to maximize opportunities for scholarship recipients to meet their 
service obligations to the IHS. It also authorizes the Secretary to 
waive or suspend a service or payment obligation upon death, extreme 
hardship conditions or bankruptcy. Next, the bill amends section 206 
regarding reimbursement from certain third parties of costs of health 
services to clarify the provisions for individuals in collection 
actions for services provided by IHS or tribal health facilities. These 
provisions were previously adopted by the Senate on October 31, 1995 as 
part of S. 325, the Native American Technical Corrections Act. However, 
the House has not yet acted upon S. 325 because the bill contained 
provisions resulting in joint referrals to a number of House 
committees. The bill I am introducing today has been drafted to permit 
referral to just one House Committee.

  The bill also amends section 405 to continue the Medicare/Medicaid 
Demonstration Program for direct billing of Medicaid, Medicare and 
other third party payers. The demonstration program authorizes up to 
four tribally-operated IHS hospitals or clinics to participate directly 
in the billing and receipt of Medicare/Medicaid payments rather than 
through the current system of channeling payments through the IHS. The 
four participating tribes including Mississippi Choctaw Health Center, 
Bristol Bay Area Health Corporation, Choctaw Tribe of Oklahoma and 
South East Alaska Regional Health Consortium, unanimously report 
successful results and satisfaction with the program. Collections for 
some of these tribes have since doubled due to the implementation of 
the program. I have also received a strong interest from other Indian 
tribes in expanding this program so that other eligible tribal 
operators may participate in this direct billing process.
  The Medicare/Medicaid Demonstration Program is set to expire on 
September 30, 1996 at which time the Secretary of the Department of 
Health and Human Services will evaluate the program and provide a 
recommendation on whether the program should be made a permanent 
program. However, without this proposed extension, the four tribal 
participants will be forced to shut down their direct billing/
collection departments and return to the old system of IHS-managed 
collections.
  Given the highly favorable reports of the participating tribal 
programs, we are proposing to continue the program through the year 
2000 and expand the number of eligible tribal facilities from four to 
twelve. The Congress will evaluate the future of the program when the 
Secretary has submitted the final report on the project.
  Finally, the act extends the authorization for several innovative 
health care demonstration projects that were established as model 
programs to be replicated on other Indian reservations. Several of 
these demonstration projects, including the California Contract Health 
Services Demonstration Program, the Gallup Alcohol and Substance Abuse 
Demonstration Program, the Substance Abuse Counselor Education 
Demonstration Program and the Home and Community Based Care 
Demonstration Program, are due to sunset in this fiscal year.
  While the programs expire in fiscal year 1997, the Secretary is not 
required to provide a report on these programs until 1999. I believe 
that these programs should be reauthorized through the year 2000 in 
order to continue the important health care services provided by these 
programs and to achieve consistency with other portions of the act. The 
bill will simply extend the authorization for these programs through 
the year 2000 until such time that the Secretary prepares his report on 
the entire Indian Health Care Improvement Act.
  Mr. President, this legislation is necessary to ensure the 
continuation of these important health care programs for Indian people. 
It is my hope that we can move this bill quickly and favorably. I urge 
my colleagues to support the immediate passage of this legislation.
  I ask unanimous consent that the full text of this bill and the 
section-by-section summary be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1869

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

     SECTION 1. SHORT TITLE; REFERENCES.

       (a) Short Title.--This Act may be cited as the ``Indian 
     Health Care Improvement Technical Corrections Act of 1996''.
       (b) References.--Whenever in this Act 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 
     Indian Health Care Improvement Act.

     SEC. 2. TECHNICAL CORRECTIONS IN THE INDIAN HEALTH CARE 
                   IMPROVEMENT ACT.

       (a) Definition of Health Profession.--Section 4(n) (25 
     U.S.C. 1603(n)) is amended--
       (1) by inserting ``allopathic medicine,'' before ``family 
     medicine''; and
       (2) by striking ``and allied health professions'' and 
     inserting ``an allied health profession, or any other health 
     profession''.
       (b) Indian Health Professions Scholarships.--Section 104(b) 
     of the Indian Health Care Improvement Act (25 U.S.C. 
     1613a(b)) is amended--
       (1) in paragraph (3)--
       (A) in subparagraph (A)--
       (i) by striking the matter preceding clause (i) and 
     inserting the following:
       ``(3)(A) The active duty service obligation under a written 
     contract with the Secretary under section 338A of the Public 
     Health Service Act (42 U.S.C. 254l) that an individual has 
     entered into under that section shall, if that individual is 
     a recipient of an Indian Health Scholarship, be met in full-
     time practice, by service--'';
       (ii) by striking ``or'' at the end of clause (iii);
       (iii) by striking the period at the end of clause (iv) and 
     inserting ``; or''; and

[[Page S6227]]

       (iv) by adding at the end the following new clause:
       ``(v) in an academic setting (including a program that 
     receives funding under section 102, 112, or 114, or any other 
     academic setting that the Secretary, acting through the 
     Service, determines to be appropriate for the purposes of 
     this clause) in which the major duties and responsibilities 
     of the recipient are the recruitment and training of Indian 
     health professionals in the discipline of that recipient in a 
     manner consistent with the purpose of this title, as 
     specified in section 101.'';
       (B) by redesignating subparagraphs (B) and (C) as 
     subparagraphs (C) and (D), respectively;
       (C) by inserting after subparagraph (A) the following new 
     subparagraph:
       ``(B) At the request of any individual who has entered into 
     a contract referred to in subparagraph (A) and who receives a 
     degree in medicine (including osteopathic or allopathic 
     medicine), dentistry, optometry, podiatry, or pharmacy, the 
     Secretary shall defer the active duty service obligation of 
     that individual under that contract, in order that such 
     individual may complete any internship, residency, or other 
     advanced clinical training that is required for the practice 
     of that health profession, for an appropriate period (in 
     years, as determined by the Secretary), subject to the 
     following conditions:
       ``(i) No period of internship, residency, or other advanced 
     clinical training shall be counted as satisfying any period 
     of obligated service that is required under this section.
       ``(ii) The active duty service obligation of that 
     individual shall commence not later than 90 days after the 
     completion of that advanced clinical training (or by a date 
     specified by the Secretary).
       ``(iii) The active duty service obligation will be served 
     in the health profession of that individual, in a manner 
     consistent with clauses (i) through (v) of subparagraph 
     (A).'';
       (D) in subparagraph (C), as so redesignated, by striking 
     ``prescribed under section 338C of the Public Health Service 
     Act (42 U.S.C. 254m) by service in a program specified in 
     subparagraph (A)'' and inserting ``described in subparagraph 
     (A) by service in a program specified in that subparagraph''; 
     and
       (E) in subparagraph (D), as so redesignated--
       (i) by striking ``Subject to subparagraph (B),'' and 
     inserting ``Subject to subparagraph (C),''; and
       (ii) by striking ``prescribed under section 338C of the 
     Public Health Service Act (42 U.S.C. 254m)'' and inserting 
     ``described in subparagraph (A)'';
       (2) in paragraph (4)--
       (A) in subparagraph (B), by striking the matter preceding 
     clause (i) and inserting the following:
       ``(B) the period of obligated service described in 
     paragraph (3)(A) shall be equal to the greater of--''; and
       (B) in subparagraph (C), by striking ``(42 U.S.C. 
     254m(g)(1)(B))'' and inserting ``(42 U.S.C. 254l(g)(1)(B))'';
       (3) in paragraph (5), by adding at the end the following 
     new subparagraphs:
       ``(C) Upon the death of an individual who receives an 
     Indian Health Scholarship, any obligation of that individual 
     for service or payment that relates to that scholarship shall 
     be canceled.
       ``(D) The Secretary shall provide for the partial or total 
     waiver or suspension of any obligation of service or payment 
     of a recipient of an Indian Health Scholarship if the 
     Secretary determines that--
       ``(i) it is not possible for the recipient to meet that 
     obligation or make that payment;
       ``(ii) requiring that recipient to meet that obligation or 
     make that payment would result in extreme hardship to the 
     recipient; or
       ``(iii) the enforcement of the requirement to meet the 
     obligation or make the payment would be unconscionable.
       ``(E) Notwithstanding any other provision of law, in any 
     case of extreme hardship or for other good cause shown, the 
     Secretary may waive, in whole or in part, the right of the 
     United States to recover funds made available under this 
     section.
       ``(F) Notwithstanding any other provision of law, with 
     respect to a recipient of an Indian Health Scholarship, no 
     obligation for payment may be released by a discharge in 
     bankruptcy under title 11, United States Code, unless that 
     discharge is granted after the expiration of the 5-year 
     period beginning on the initial date on which that payment is 
     due, and only if the bankruptcy court finds that the 
     nondischarge of the obligation would be unconscionable.''.
       (c) Reimbursement From Certain Third Parties of Costs of 
     Health Services.--Section 206 (16 U.S.C. 1621e) is amended--
       (1) in subsection (a)--
       (A) in the matter preceding paragraph (1)--
       (i) by striking ``Except as provided'' and inserting ``(a) 
     Right of Recovery.--Except as provided'';
       (ii) by striking ``the reasonable expenses incurred'' and 
     inserting ``the reasonable charges billed'';
       (iii) by striking ``in providing'' and inserting ``for 
     providing''; and
       (iv) by striking ``for such expenses'' and inserting ``for 
     such charges''; and
       (B) in paragraph (2), by striking ``such expenses'' each 
     place it appears and inserting ``such charges'';
       (2) in subsection (b), by striking ``(b) Subsection (a)'' 
     and inserting ``(b) Recovery Against State With Workers' 
     Compensation Laws or No-Fault Automobile Accident Insurance 
     Program.--Subsection (a)'';
       (3) in subsection (c), by striking ``(c) No law'' and 
     inserting ``(c) Prohibition of State Law or Contract 
     Provision Impediment to Right of Recovery.--No law'';
       (4) in subsection (d), by striking ``(d) No action'' and 
     inserting ``(d) Right to Damages.--No action'';
       (5) in subsection (e)--
       (A) in the matter preceding paragraph (1), by striking 
     ``(e) The United States'' and inserting ``(e) Intervention or 
     Separate Civil Action.--The United States''; and
       (B) by striking paragraph (2) and inserting the following 
     new paragraph:
       ``(2) while making all reasonable efforts to provide notice 
     of the action to the individual to whom health services are 
     provided prior to the filing of the action, instituting a 
     civil action.'';
       (6) in subsection (f), by striking ``(f) The United 
     States'' and inserting ``(f) Services Covered Under a Self-
     Insurance Plan.--The United States''; and
       (7) by adding at the end the following new subsections:
       ``(g) Costs of Action.--In any action brought to enforce 
     this section, the court shall award any prevailing plaintiff 
     costs, including attorneys' fees that were reasonably 
     incurred in that action.
       ``(h) Right of Recovery for Failure To Provide Reasonable 
     Assurances.--The United States, an Indian tribe, or a tribal 
     organization shall have the right to recover damages against 
     any fiduciary of an insurance company or employee benefit 
     plan that is a provider referred to in subsection (a) who--
       ``(1) fails to provide reasonable assurances that such 
     insurance company or employee benefit plan has funds that are 
     sufficient to pay all benefits owed by that insurance company 
     or employee benefit plan in its capacity as such a provider; 
     or
       ``(2) otherwise hinders or prevents recovery under 
     subsection (a), including hindering the pursuit of any claim 
     for a remedy that may be asserted by a beneficiary or 
     participant covered under subsection (a) under any other 
     applicable Federal or State law.''.
       (d) California Contract Health Services Demonstration 
     Program.--Section 211(g) (25 U.S.C. 1621j(g)) is amended by 
     striking ``1993, 1994, 1995, 1996, and 1997'' and inserting 
     ``1996 through 2000''.
       (e) Medicare and Medicaid Demonstration Program.--Section 
     405(c) (42 U.S.C. 1395qq note) is amended--
       (1) in paragraph (1)(D), by striking ``prior to October 1, 
     1990'' and inserting ``on or before the date which is 1 year 
     after the date of submission of the plan''; and
       (2) in paragraph (2)--
       (A) by striking ``, prior to October 1, 1989, select no 
     more than 4'' and inserting ``select no more than 12''; and
       (B) by striking ``September 30, 1996'' and inserting 
     ``September 30, 2000''.
       (f) Gallup Alcohol and Substance Abuse Treatment Center.--
     Section 706(d) (25 U.S.C. 1665e(d)) is amended to read as 
     follows:
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated, for each of fiscal years 1996 
     through 2000, such sums as may be necessary to carry out 
     subsection (b).''.
       (g) Substance Abuse Counselor Education Demonstration 
     Program.--Section 711(h) (25 U.S.C. 1665j(h)) is amended by 
     striking ``1993, 1994, 1995, 1996, and 1997'' and inserting 
     ``1996 through 2000''.
       (h) Home and Community-Based Care Demonstration Program.--
     Section 821(i) (25 U.S.C. 1680k(i)) is amended by striking 
     ``1993, 1994, 1995, 1996, and 1997''and inserting ``1996 
     through 2000''.
                                                                    ____


 Section-by-Section Summary--Indian Health Care Improvement Technical 
                        Corrections Act of 1996

       Section 1(a) sets forth the short title of the Act.
       Section 1(b) provides that wherever a section or other 
     provision is amended or repealed in this Act, such amendment 
     shall be considered made to the referenced section or 
     provision of the Indian Health Care Improvement Act (25 
     U.S.C. 1601 et. seq.).
       Section 2(a) amends Section 4(n) of the Indian Health Care 
     Improvement Act to modify the definition of ``Health 
     Profession'' to specify that ``allopathic medicine'' shall be 
     added as an eligible degree program for individuals to 
     qualify for scholarships and loan repayment programs. This 
     section also modifies the definition by striking the current 
     language of ``and allied health professions'' and inserting 
     ``an allied health profession, or any other health 
     profession'' to allow the IHS additional flexibility to 
     determine eligibility for scholarships and loan repayments 
     for individuals enrolled in health professions not specified 
     under this section.
       Section 2(b) amends Section 104(b) of the Indian Health 
     Care Improvement Act to add a new provision that clarifies 
     that an individual serving in an academic setting that is 
     funded under sections 102, 112, or 114 of the Act who is 
     responsible for the recruitment and training of Indian Health 
     Professionals shall be considered to be meeting their service 
     obligations under section 338A of the Public Health Service 
     Act. This provision will allow an individual to meet their 
     service obligation to the IHS by working at a university or 
     other academic setting which is responsible for recruiting 
     and training American Indians in the health professions. This

[[Page S6228]]

     is also intended to clarify that the Secretary may defer an 
     individual's service obligation during the term of an 
     internship, residency or other advanced clinical program. 
     Section 104(b) is further amended by adding new subsections 
     to address unique circumstances under which the Secretary to 
     authorized to waive or suspend service or payment obligations 
     due to death or the Secretary's determination that it would 
     cause extreme hardship or to enforce such a requirement would 
     be unconscionable. An additional subsection is added to 
     clarify the terms under which an individual's payment 
     obligation may be discharged in a bankruptcy proceeding.
       Section 2(c) amends Section 206 of the Indian Health Care 
     Improvement Act to clarify the notice provisions for 
     individuals in collection actions for services provided by 
     IHS or tribal health facilities and recoverable costs in such 
     a collection action and the right of the United States and 
     Indian tribes to recover against an insurance company or 
     employee benefit plan.
       Section 2(d) amends Section 211(g) of the Indian Health 
     Care Improvement Act to extend the authorization for the 
     California Contract Health Services Demonstration Program 
     until the year 2000.
       Section 2(e) amends Section 405(c) of the Indian Health 
     Care Improvement Act to provide that applicants for the 
     Medicare and Medicaid Demonstration Program must be 
     accredited by the Joint Commission on Accreditation of 
     Hospitals within one year of submission of an application. 
     Section 405(c) is amended to increase the number of eligible 
     tribal health facilities from four to twelve. The 
     authorization for the Medicare and Medicaid Demonstration 
     Program is extended until the year 2000.
       Section 2(f) amends Section 706(d) of the Indian Health 
     Care Improvement Act to strike out 706(d) in its entirety and 
     add a new subsection that will extend the authorization for 
     the Gallup Alcohol and Substance Abuse Treatment Center until 
     the year 2000.
       Section 2(g) amends Section 711(h) of the Indian Health 
     Care Improvement Act to extend the authorization for the 
     Substance Abuse Counselor Education Demonstration Program 
     until the year 2000.
       Section 2(h) amends Section 821(I) of the Indian Health 
     Care Improvement Act to extend the authorization for the Home 
     and Community-Based Care Demonstration Program until the year 
     2000.
                                 ______