[Congressional Record Volume 147, Number 147 (Tuesday, October 30, 2001)]
[Senate]
[Pages S11199-S11216]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. LIEBERMAN (for himself and Mr. Ensign):
  S. 1585. A bill to establish grant and scholarship programs to enable 
hospitals to retain and further educate their nursing staffs; to the 
Committee on Health, Education, Labor, and Pensions.
  Mr. LIEBERMAN. Madam President, I rise today to introduce the 
Hospital Based Nursing Initiative Act, a bill that will create new and 
innovative incentives to lessen the impact of the critical shortage of 
nurses in our Nation's hospitals. I am very pleased that my respected 
colleague, Senator John Ensign, is joining as sponsor of this 
legislation/
  Before I get into the specific about the bill, I'd like to talk about 
the overall condition of nursing in America for a moment. Several 
studies have been completed in the past year that show troubling trends 
developing in this historic profession. Take for example, the study 
that reflects a 41 percent dissatisfaction rate among nurses in 
America, higher than the dissatisfaction rate in most other countries 
throughout the world. Think about that for a moment, 4 out of 10 nurses 
in America are dissatisfied with their profession.
  Another study reveals that nearly one third of nurses under the age 
of 30 plan to leave the nursing profession within the next year. In 
addition, the average age of nurses in America is 45, with many nurses 
headed toward early retirement. We cannot afford to lose both the older 
and younger nurses at the same time. Further, while the number of 
people that are being hospitalized may continue to decrease, those 
people who are being admitted are sicker and need more intensive 
nursing care. Not a very rosy picture for patients who are sick. We 
need to ask will there be someone to provide care for them?
  The shortage of nurses has severely affected the health care 
industry. And hospitals have been hit the hardest since nearly 60 
percent of nurses work in hospitals. Further, we know that when nurses 
have more autonomy, greater control and input into the decision making 
process, and better communication with physicians and hospital 
administration, they are more likely to experience greater job 
satisfaction and stay in their jobs longer. These very tenets make up 
the American Nurse Credentialing Center's ``Magnet'' accreditation 
process of nursing services at hospitals. As a result, Magnet hospitals 
lead the way in attracting and retaining nurses.
  Many hospitals have begun to take these steps already. But more must 
be done. There must be incentives for hospitals to revise their 
management principles to improve the quality of the work environment in 
the hospital, initiate aggressive retention programs for nurses 
currently working in the hospital setting, and create the types of 
programs that will increase personal and professional satisfaction for 
the nurses in their facilities.
  That is why I am introducing the Hospital Based Nursing Initiative 
Act of 2001. This bill will create innovative incentives for hospitals 
that have taken the first steps in developing aggressive retention 
techniques and develop a scholarship program for hospital-based nurses 
to return to school on full tuition scholarship to complete a nursing 
degree.
  The first component of this bill will create a competitive grant 
program that would provide funds to hospitals of up to $600,000 based 
on staffed bed size for nursing services to use to bolster their 
retention efforts and improve the work environment for the nursing 
staff in the hospital. These grants would be made available every two 
years on a competitive basis. Several major nursing and hospital 
organizations, such as the American Hospital Association, American 
Nurses Association, American College of Health Care Executives, the 
American Organization of Nurse Executives, the American Academy of 
Nursing, the Pennsylvania State Nurses Association and the American 
Federation of Hospitals have wholeheartedly endorsed this bill. I am 
pleased that legislation which incorporates a number of ideas in this 
bill is moving toward markup in the Senate Health, Education, Labor and 
Pensions Committee. I appreciate the cooperative spirit with which 
members of the committee have worked together on these ideas.
  The second part of my bill would allow nurses who work in hospitals 
to return to school on a full tuition scholarship in order to complete 
a Bachelor of Science in Nursing. This ``Bridge'' scholarship program 
targets the nearly 55 percent of the nursing workforce who hold an 
Associate's Degree in Nursing or Diploma in Nursing. Under the Bridge 
program, nurses will have up to three years to complete the Bachelor's 
degree. In turn, nurses who accept the scholarship must agree to work 
in the sponsoring hospitals for the same number of months that they 
receive scholarship funding. This program is a win-win situation: It 
provides ongoing advanced education for nurses who seek a higher level 
of training and we keep skilled nurses working in our hospitals.
  We have the opportunity to make a difference. With the bill that 
Senator

[[Page S11200]]

Ensign and I are now introducing, we can take the necessary steps to 
thwart the nursing shortage and provide the critical incentives for 
hospitals to retain their nurses. We must do all we can to improve job 
satisfaction for nurses, provide them with opportunities for advanced 
education, and keep nurses on the job. The Hospital Based Nursing 
Initiative is the right bill at the right time. I urge my colleagues to 
support this legislation and help ease the burden on hospitals and 
nurses in our hospitals.
  I ask unanimous consent that the text of the bill be printed in the 
Record. I further ask unanimous consent that letters supporting this 
legislation and its approach from each of the organizations I cited 
above likewise be printed in the Record.
  There being no objection, the bill and additional material was 
ordered to be printed in the Record, as follows:

                                S. 1585

       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 ``Hospital-Based Nursing 
     Initiative Act of 2001''.

     SEC. 2. FINDINGS.

       Congress finds that--
       (1) a Department of Health and Human Services study found a 
     correlation between the number of registered nurses on the 
     staff of a facility and patient health outcomes;
       (2) studies have shown that hospitals that promote greater 
     autonomy for nurses, greater nurse control and input into the 
     decisionmaking process in the hospital setting, better 
     communication between nurses and physicians, and input from 
     nurses at the executive level in the hospital lead to 
     increased retention of and satisfaction for nurses;
       (3) the job dissatisfaction rate among nurses in the United 
     States, 41 percent, is higher than in most other countries;
       (4) \1/3\ of nurses under the age of 30 are planning to 
     leave the nursing profession within the next year;
       (5) hospitals employ nearly 60 percent of the entire 
     nursing workforce;
       (6) while the number of inpatient hospitalizations is 
     expected to continue to decrease, the acuity of those 
     patients requiring hospital stays is expected to increase;
       (7) the projected supply of registered nurses is 
     anticipated to grow at a rate of less than 1.5 percent per 
     year through the next 8 years, while the demand rate (growth) 
     is projected to be over 21 percent per year;
       (8) there must be incentives for hospitals to revise 
     management principles to improve the quality of the work 
     environment in hospitals, initiate aggressive retention 
     programs for the nurses currently employed in hospital 
     settings, and employ aggressive recruiting tactics to attract 
     nurses back to hospital settings; and
       (9) while numerous hospitals have begun to take the 
     necessary steps to address these issues, Congress recognizes 
     the need for intervention and stimulus.

     SEC. 3. NURSE GRANT AND SCHOLARSHIP PROGRAMS.

       Title VIII of the Public Health Service Act (42 U.S.C. 296 
     et seq.) is amended by adding at the end the following:

             ``PART H--NURSE GRANT AND SCHOLARSHIP PROGRAM

     ``SEC. 851. DEFINITIONS.

       ``In this part:
       ``(1) Division.--The term `Division' means the Nursing 
     Division of the Bureau of Health Professions of the Health 
     Resources and Services Administration.
       ``(2) Nurse leadership.--The term `nurse leadership' 
     includes--
       ``(A) nurse executives;
       ``(B) nurse administrators; and
       ``(C) nurse managers.
       ``(3) Professional nurse.--The term `professional nurse' 
     means a registered nurse who holds a valid and unrestricted 
     license to practice nursing in a State.

     ``SEC. 852. QUALITY OF WORK ENVIRONMENT AND RETENTION GRANT 
                   PROGRAM.

       ``(a) Authorization of Grants.--The Secretary may award 
     grants to hospitals--
       ``(1) to improve the quality of the work environment in 
     hospitals;
       ``(2) to initiate aggressive retention programs for nurses 
     employed in hospitals; and
       ``(3) to employ aggressive recruiting tactics to attract 
     nurses back to hospitals.
       ``(b) Application.--
       ``(1) Development of application form.--Not later than 
     October 1, 2002, the Secretary shall develop an application 
     form that a hospital shall use in applying for a grant under 
     this section.
       ``(2) Submission.--Each hospital desiring a grant under 
     subsection (a) shall submit an application to the Division at 
     such time, in such manner, and accompanied by such 
     information as the Secretary may reasonably require.
       ``(3) Duties of the division.--The Division shall--
       ``(A) review each application submitted under paragraph 
     (2); and
       ``(B) not later than 30 business days after receipt of an 
     application submitted under paragraph (2), forward the 
     application to the Secretary with a recommendation as to 
     whether the Secretary should award a grant to the applicant.
       ``(4) Duties of the secretary.--Not later than 30 business 
     days after receipt of an application from the Division under 
     paragraph (3), the Secretary shall determine whether to award 
     a grant to the applicant.
       ``(c) Grant Approval Criteria.--
       ``(1) Priority criteria.--The Secretary shall give priority 
     in awarding grants under this section to hospitals that have 
     not previously received a grant under this section.
       ``(2) Requirements.--Before awarding a grant under 
     subsection (a), the Secretary shall assure that the hospital 
     meets the following criteria:
       ``(A) Multiple grants.--The hospital has not received a 
     grant under this section during the previous 2 year period.
       ``(B) System of patient outcomes measurement.--
       ``(i) In general.--The nurse leadership and professional 
     nurses of the hospital have developed a system of patient 
     outcomes measurement.
       ``(ii) Delivery of care.--The system of patient outcomes 
     measurement under clause (i) evaluates the specific care 
     needs of the patients served by the hospital and the 
     educational needs of the nursing staff of the hospital to 
     ensure that the care the hospital is providing is meeting the 
     needs of the patients.
       ``(iii) Funding.--The hospital allocates sufficient funds 
     to carry out the system of patient outcomes measurement under 
     clause (i).
       ``(C) Decisionmaking.--
       ``(i) Multidisciplinary approach.--The hospital uses a 
     multidisciplinary decisionmaking process that incorporates 
     the input of the nursing staff of the hospital when 
     refinements, resulting from the evaluation under subparagraph 
     (B)(ii), are developed.
       ``(ii) Participation in decisionmaking.--The nurse 
     leadership of the hospital has developed and implemented 
     policies and practices that--

       ``(I) ensure participation of the nursing staff of the 
     hospital in the decisionmaking processes of the hospital; and
       ``(II) foster the nursing staff's ability to maintain 
     autonomy in the delivery of care.

       ``(D) Nurse executive participation.--The nurse executive 
     in the hospital participates and provides input in all facets 
     of senior level management as a member of the executive team 
     of the hospital.
       ``(E) Nurse retention committee.--The nurse leadership of 
     the hospital has organized a Nurse Retention Committee that--
       ``(i) includes nursing staff representatives from the 
     various nursing specialties practicing in the hospital;
       ``(ii) meets on a regular basis and forwards 
     recommendations for initiatives to increase nurse retention 
     to the nurse leadership; and
       ``(iii) works with the nurse leadership of the hospital to 
     address and forward the recommendations under clause (ii) to 
     the executive team of the hospital.
       ``(F) Nurse residency training program.--
       ``(i) In general.--The hospital has developed a Nurse 
     Residency Training Program (referred to in this section as 
     the `NRTP') for--

       ``(I) new graduate nurses entering the workforce on a full-
     time basis in a hospital setting; and
       ``(II) nurses returning to a hospital staff on a full-time 
     basis after an absence of not less than 3 years without 
     working in the nursing field.

       ``(ii) Returning nurses.--The nurse leadership of the 
     hospital evaluates the skills and competencies of each nurse 
     described in clause (i)(II) to determine--

       (I) whether that nurse needs to participate in the NRTP; 
     and
       (II) for how long that nurse should participate in the NRTP 
     if it is determined under subclause (I) that the nurse needs 
     to participate in the NRTP.

       ``(iii) Training.--The--

       ``(I) hospital coordinates, to the greatest extent 
     possible, the NRTP with an accredited school of nursing; or
       ``(II) NRTP is not less than 3 months and not more than 1 
     year in duration and accommodates sufficient training 
     opportunities as determined by the nurse leadership in the 
     facility.

       ``(G) Continuing education.--The hospital promotes and, to 
     the greatest extent possible, provides continuing education 
     for the nursing staff--
       ``(i) to obtain nursing-related certification;
       ``(ii) to maintain continuing education units as required 
     for nursing-licensure; and
       ``(iii) to further clinical skills through advanced 
     training opportunities.
       ``(H) Recognition and reward program.--The hospital has 
     developed a recognition and reward program in conjunction 
     with subparagraph (G) for a nurse who obtains a nursing-
     related certification from an accredited or professionally 
     recognized organization that provides--
       ``(i) financial recognition and rewards; or
       ``(ii) non-financial recognition and rewards that are 
     determined by the Nurse Retention Committee of the hospital 
     to be appropriate.
       ``(d) Allocation.--
       ``(1) In general.--The Secretary shall determine the amount 
     of a grant awarded to a hospital under this section on a case 
     by case basis subject to paragraph (2).
       ``(2) Maximum amounts.--The Secretary shall not award a 
     grant exceeding--
       ``(A) $200,000 for a hospital with less than 100 staffed 
     beds;

[[Page S11201]]

       ``(B) $400,000 for a hospital with less than 400 staffed 
     beds; and
       ``(C) $600,000 for a hospital with 400 or more staffed 
     beds.
       ``(e) Receipt of Funds.--Not later than 60 days after 
     awarding a grant to a hospital under subsection (a), the 
     Secretary shall distribute the grant funds to the hospital.
       ``(f) Uses of Funds.--A grant awarded to a hospital under 
     subsection (a) shall be used for 1 or more of the following:
       ``(1) Improvements to the work environment of the hospital 
     for the nursing staff that improves the nursing staff's job 
     satisfaction or safety, or both.
       ``(2) To provide continuing education programs for the 
     nursing staff.
       ``(3) To continue the Nurse Residency Training Program.
       ``(4) To carry out initiatives recommended by the Nursing 
     Retention Committee of the hospital to increase retention of 
     the nursing staff.
       ``(g) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $30,000,000 for 
     each of fiscal years 2003 through 2005 and such sums as are 
     necessary for each of fiscal years 2006 and 2007.

     ``SEC. 853. BRIDGE SCHOLARSHIP PROGRAM.

       ``(a) Program Authorized.--The Secretary shall establish a 
     Bridge Scholarship Program (referred to in this section as 
     the `program') to provide scholarships to hospital-based 
     professional nurses to enable such nurses to complete a 
     Bachelor of Science in Nursing degree (referred to in this 
     section as the `degree') in exchange for service from such 
     nurses in sponsoring hospitals upon completion of such 
     degree.
       ``(b) Eligibility.--To be eligible to participate in the 
     program an individual shall--
       ``(1) be employed by a hospital;
       ``(2) be accepted for enrollment, or be enrolled, in an 
     accredited school of nursing;
       ``(3) submit the required materials in accordance with 
     subsection (c)(2); and
       ``(4) be able to complete the degree not later than 3 years 
     after enrolling in the accredited school of nursing.
       ``(c) Application Process.--
       ``(1) Development of application form.--The Secretary shall 
     develop an application form that an individual shall use to 
     apply for a scholarship under the program.
       ``(2) Submission.--Each individual desiring a scholarship 
     under the program shall submit to the hospital where the 
     individual is employed--
       ``(A) an official letter from each State licensing agency 
     where the individual is licensed to practice nursing that the 
     individual--
       ``(i) has an unrestricted license to practice nursing; and
       ``(ii) is in good standing;
       ``(B) an application for participation in the program;
       ``(C) proof of acceptance for enrollment, or enrollment in, 
     an accredited school of nursing; and
       ``(D) a written contract accepting payment of a scholarship 
     in exchange for providing the required service in the 
     hospital where the individual is employed.
       ``(3) Duty of the hospital.--A hospital that receives the 
     materials described in paragraph (2) shall--
       ``(A) make a determination as to whether to enter into the 
     contract under paragraph (2)(D) with the individual; and
       ``(B) if the hospital elects to enter into the contract 
     with the individual, not later than May 31 of each calendar 
     year, forward the materials it receives under paragraph (2) 
     to the Division.
       ``(4) Duties of the division.--The Division shall--
       ``(A) review the materials forwarded under paragraph (3); 
     and
       ``(B) not later than 30 days after receipt of the materials 
     forwarded under paragraph (3), forward the materials to the 
     Secretary with a recommendation as to whether the Secretary 
     should award a scholarship to the applicant.
       ``(5) Duties of the secretary.--Not later than 30 days 
     after--
       ``(A) receipt of the materials forwarded under paragraph 
     (4), the Secretary shall approve or disapprove the 
     application submitted under paragraph (2); and
       ``(B) the Secretary approves or disapproves an application 
     under subparagraph (A), the Secretary shall notify the 
     applicant in writing of the approval or disapproval.
       ``(d) Contract.--
       ``(1) In general.--The Secretary shall develop a written 
     contract for participation in the program.
       ``(2) Content.--The contract described in paragraph (1) 
     shall be an agreement between the Secretary, the individual, 
     and the sponsoring hospital that states that, subject to 
     paragraph (3)--
       ``(A) the Secretary agrees to--
       ``(i) provide the individual with a scholarship in each 
     school year, not to exceed 3 years, in which the individual 
     is pursuing the degree; and
       ``(ii) accept the individual into the program;
       ``(B) the individual agrees to--
       ``(i) accept any provision of such a scholarship;
       ``(ii) maintain enrollment in the accredited school of 
     nursing until the individual completes the degree;
       ``(iii) while enrolled in the accredited school of nursing, 
     maintain an acceptable level of academic standing; and
       ``(iv) work as a nurse at the sponsoring hospital upon 
     completion of the degree for a period of 1 month for each 
     month the individual was provided a scholarship under the 
     program; and
       ``(C) the sponsoring hospital agrees to--
       ``(i) provide the option for the individual to work as a 
     nurse while the individual is enrolled in the accredited 
     school of nursing for any employment-shifts on which the 
     individual and sponsoring hospital jointly agree (such work 
     will not count towards the requirements of the individual to 
     work at the sponsoring hospital under subparagraph (B)(iv)); 
     and
       ``(ii) if the sponsoring hospital terminates the employment 
     of the individual while the individual is working at the 
     sponsoring hospital pursuant to subparagraph (B)(iv), submit 
     to the Secretary a written explanation as to why the 
     individual was terminated.
       ``(3) Limitation.--The contract described in paragraph (1) 
     shall contain a provision that any financial obligation of 
     the United States arising out of a contract entered into 
     under this section and any obligation of the individual and 
     the sponsoring hospital which is conditioned thereon, is 
     contingent upon funds being appropriated for scholarships 
     under this section.
       ``(e) Payment.--
       ``(1) In general.--A scholarship provided to an individual 
     under the program shall consist of payment to, or (in 
     accordance with paragraph (2)) on behalf of, the individual 
     of the amount of the tuition of the individual in such school 
     year.
       ``(2) Contract.--The Secretary may contract with an 
     accredited school of nursing, in which an individual in the 
     program is enrolled, for the payment to the accredited school 
     of nursing of the amount of tuition described in paragraph 
     (1).
       ``(f) Breach of Agreement.--
       ``(1) Individual.--Subject to paragraph (3), if an 
     individual participates in the program under this section and 
     agrees to work as a nurse at the sponsoring hospital for a 
     period of time in consideration for receipt of a scholarship 
     to pursue a degree, the individual is liable to the Federal 
     Government for the amount of such scholarship, and for 
     interest on such amount at the maximum legal prevailing rate, 
     if the individual--
       ``(A) fails to work as a nurse in accordance with 
     subsection (d)(2)(B)(iv);
       ``(B) fails to maintain an acceptable level of academic 
     standing in the degree program (as indicated by the 
     accredited school of nursing in accordance with requirements 
     established by the Secretary);
       ``(C) is dismissed from the degree program for disciplinary 
     reasons; or
       ``(D) voluntarily terminates the degree program.
       ``(2) Sponsoring hospital.--If the sponsoring hospital 
     fails to comply with subsection (d)(2)(C)(ii), the sponsoring 
     hospital is liable to the Federal Government for the amount 
     of the scholarship, and for interest on such amount at the 
     maximum legal prevailing rate, of the individual whose 
     employment was terminated.
       ``(3) Waiver or suspension of liability.--The Secretary 
     shall waive liability--
       ``(A) under paragraph (1) if compliance by the individual 
     with the agreement involved is impossible due to a 
     catastrophic life event of the individual; or
       ``(B) under paragraph (1)(A) if the sponsoring hospital 
     terminates the employment of the individual.
       ``(g) Report.--
       ``(1) In general.--Not later than 18 months after the first 
     scholarship is awarded under this section, the Division shall 
     submit to Congress a report evaluating the success of the 
     program.
       ``(2) Information.--In order to prepare the report under 
     paragraph (1), the Division shall maintain information about 
     the scholarship recipients under this section, including--
       ``(A) grade reports from the accredited schools of nursing;
       ``(B) the degree graduation rate; and
       ``(C) the default rate on the contracts under the program.
       ``(h) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $20,000,000 for 
     each of fiscal years 2003 through 2005 and such sums as are 
     necessary for each of fiscal years 2006 and 2007.''.
                                  ____



                                American Hospital Association,

                                  Washington, DC, October 8, 2001.
     Hon. Joseph Lieberman,
     U.S. Senate, Washington, DC.
       Dear Senator Lieberman: The American Hospital Association 
     (AHA) commends your efforts to address the nursing workforce 
     shortage in your bill, The Hospital-Based Nursing Initiative 
     Act of 2001, and is pleased to endorse your legislation. We 
     believe your bill is an important component in the overall 
     strategy of addressing the national nursing shortage.
       The AHA represents nearly 5,000 hospitals, health systems, 
     networks and other health care provider members.
       Hospitals and health care facilities across America are 
     experiencing a critical shortage of nurses. A recent AHA 
     survey of the workforce shows that there are currently up to 
     126,000 Registered Nurses (RNs) needed by hospitals today. 
     Over the past five years, enrollments in nursing programs 
     have declined and this trend is expected to continue for the 
     foreseeable future. The average age of a working RN is now 
     over 43 years old, and is expected to continue to increase 
     before peaking at age 45.5 in 2010, when many RNs will

[[Page S11202]]

     begin to retire. And, the need for nurses will be further 
     compounded by the potential health care demands of the 
     looming 78 million aging ``baby boomers'' who will begin to 
     retire over the next 10 years.
       The current nursing shortage is creating an environment 
     with the potential to jeopardize hospitals' ability to 
     provide timely access to non-emergency, as well as emergency, 
     services. An inadequate number and mix of personnel has 
     caused some facilities to close beds, put emergency rooms on 
     ``divert'' status, delay elective surgeries, and pare down 
     hospital services.
       Hospitals have enlisted many strategies and creative 
     approaches to address the nursing shortage, but this is a 
     complex problem that cannot be solved by hospitals alone. The 
     role of the federal government is critical in the support and 
     funding of an adequate nursing workforce.
       ``The Hospital-Based Nursing Initiative Act of 2001'' 
     provides significant incentives for hospitals to examine and 
     revise management principles to improve the quality of their 
     work environment, and to foster effective RN retention 
     programs. It establishes incentives for hospitals to develop 
     and implement aggressive recruitment programs to attract 
     nurses into the hospital setting. The legislation also 
     creates bridge programs for RNs currently employed in 
     hospitals to move up the career ladder, a significant 
     recruitment and retention tool.
       Helping alleviate the critical shortage of nurses is a 
     priority for health care providers. As we debate this and 
     other measures to address the nursing shortage, we hope 
     Congress will recognize the important of investing in this 
     critical area of need. We applaud your effort and pledge to 
     work with you to address this very important issue.
           Sincerely,
                                                     Rick Pollack,
     Executive Vice President.
                                  ____

                                             American Organization


                                          of Nurse Executives,

                               Washington, DC, September 14, 2001.
     Hon. Joseph I. Lieberman,
     U.S. Senate, Washington, DC.
       Dear Senator Lieberman: On behalf of more than 3800 members 
     of the American Organization of Nurse Executives (AONE) 
     representing nurses in executive practice, I would like to 
     express our strong support for the ``Hospital-Based Nursing 
     Initiative Act of 2001,'' legislation that you have authored 
     and plan to introduce to address the critical nurse shortage.
       During the past year, AONE has played a pivotal role in 
     addressing the nursing shortage. In October 2000 we published 
     the first comprehensive monograph on this critical issue 
     entitled Perspectives on the Nursing Shortage: A Blueprint 
     for Action and have continued to provide both education and 
     advocacy for the nursing profession on a number of different 
     fronts. Your bill will provide important management 
     incentives for hospitals to revise their management of 
     nursing services in order to foster retention and promote 
     recruitment of nurses back into the inpatient delivery 
     system.
       The majority of AONE's membership are leaders in the day-
     to-day management and delivery of direct patient care 
     services, as a result, we understand firsthand the impacts 
     and consequences of the growing nursing shortage both in this 
     country and internationally. Our support of the ``Hospital-
     Based Nursing Initiative Act of 2001'' is based on the 
     positive contributions that this legislation will make to 
     nurse-directed efforts to foster retention and promote 
     recruitment of nurses within the inpatient settings of our 
     federal, community, and private hospitals. This legislation 
     will also establish important bridge programs for registered 
     nurses currently employed in hospitals to move from diploma 
     and Associate Degree levels of education on to a Bachelor of 
     Science degree within three years.
       AONE applauds your efforts to address the nursing shortage 
     through this innovative grant and scholarship program. We 
     look forward to working with you to solve this critical 
     health manpower problem.
           Sincerely,
                                      Pamela A. Thompson, MSN, RN,
                                               Executive Director.
                                          Dianne Anderson, MS, RN,
     President.
                                  ____



                                  American Nurses Association,

                               Washington, DC, September 19, 2001.
     Hon. Joseph Lieberman,
     U.S. Senate, Washington, DC.
       Dear Senator Lieberman: I am writing you on behalf of the 
     American Nurses Association (ANA) to express support for the 
     Hospital-Based Nursing Initiative Act. We applaud your hard 
     work on this important issue. ANA is the only full-service 
     association representing the nation's registered nurses (RNs) 
     through its 54 state and territorial member nurse 
     associations. With more than 160,000 members, the ANA 
     represents RNs in all practice settings throughout our 
     nation.
       ANA understands that a major contributing factor to the 
     current and emerging nursing shortage is dissatisfaction with 
     the work environment. The Congressional Research Service, 
     General Accounting Office, academic research, and recent ANA 
     surveys of American nurses have all revealed startling levels 
     of frustration with working conditions. This dissatisfaction 
     is leading experienced nurses to leave the bedside, and 
     hindering recruitment efforts.
       Fortunately, we know what can be done to address this 
     growing problem. There are proven best practices for nursing 
     that improve patient outcomes, and enhance nurse recruitment 
     and retention. The American Nurses Credentialing Center, an 
     ANA affiliate, recognizes facilities that have met these best 
     practices by granting the `Magnet' designation. Magnet 
     facilities have consistently outperformed their peers in 
     nursing services, even in times of national nursing 
     shortages. In fact, average nurse retention in Magnet 
     facilities is twice as long as that of non-Magnet 
     institutions.
       ANA is pleased to endorse your efforts to further the 
     implementation of these best practices through the Hospital-
     Based Nursing Initiative Act. The quality of work environment 
     and nurse retention grant program, and the continuing 
     education scholarships contained in your bill will greatly 
     aide in the adoption of Magnet criteria. ANA looks forward to 
     working with you and your staff to support this legislation.
           Sincerely,
                                           Rose Gonzalez, MPS, RN,
     Director, Government Affairs.
                                  ____

                                                  American College


                                     of Healthcare Executives,

                                  Chicago, IL, September 18, 2001.
     Hon. Joseph I. Lieberman,
     U.S. Senate, Washington, DC.
       Dear Senator Lieberman: Thank you for inviting the American 
     College of Healthcare Executives to review and provide 
     comments on the ``Hospital-Based Nursing Initiative Act of 
     2001.''
       Upon reviewing the bill, ACHE wishes to endorse it. This 
     legislation offers a comprehensive approach to the crisis 
     facing our nation's healthcare system--a shortage of nurses. 
     The bill attempts to address this important issue by 
     supporting hospitals in a number of ways, including: 
     retaining nurses; improving the work environment for nursing 
     staff; fostering nursing leadership; providing continuing 
     education programs for nurses; creating recognition and 
     reward programs for nurses who obtain nursing-related 
     certification; and finally, offering educational assistance 
     for nurses to earn their Bachelor of Science Degree in 
     Nursing. We believe this bill encompasses the various 
     elements to make a genuine difference and increase the 
     nursing population.
       Thank you for your work in developing this legislation. If 
     there is anything ACHE can do to assist further in this 
     endeavor, please contact Susan M. Oster, CAE, Vice President, 
     Administration at (312) 424-9340.
           Sincerely,
                               Thomas C. Dolan, Ph.D., FACHE, CAE,
     President and Chief Executive Officer.
                                  ____

                                                Pennsylvania State


                                           Nurses Association,

                               Harrisburg, PA, September 17, 2001.
     Hon. Joseph Lieberman,
     U.S. Congress, Washington, DC.
       Dear Senator Lieberman: The Pennsylvania State Nurses 
     Association (PSNA) would like to commend you for the 
     excellent legislation you plan to introduce, which is meant 
     to establish grant and scholarship programs enabling 
     hospitals to retain and further educate their nursing staffs. 
     The bill contains excellent ideas and creative solutions to 
     entice nurses to join or remain a member of a hospital 
     nursing staff.
       The focus on nurses having opportunities to participate in 
     decision-making regarding nursing care and maintaining 
     autonomy in the delivery of care are especially important 
     attractants for nurses. Also, the emphasis on having a system 
     for measuring outcomes is imperative for quality patient 
     care.
       The organization welcomes the opportunity to work with you 
     in ensuring the passage of the legislation that will greatly 
     benefit the profession of nursing and the quality of care 
     provided to consumers.
           Sincerely,
                                       Jessie F. Rohner, DrPH, RN,
                                  Interim Executive Administrator.
                                 ______
                                 
      By Mr. KERRY (for himself, Mr. Breaux, and Mr. Hollings):
  S. 1587. A bill to provide improved port and maritime security, and 
for other purposes; to the Committee on Commerce, Science, and 
Transportation.
  Mr. BREAUX. Madam President, along with Mr. Kerry, Chairman of the 
Oceans, Atmosphere and Fisheries Subcommittee, and Mr. Hollings, 
Chairman of the Commerce Committee, I rise today in support of the Port 
Threat and Security Act of 2001. I believe this legislation will help 
United States' authorities identify and counteract maritime threats 
from terrorist actions. Importantly, these provisions are designed in 
part to protect U.S. citizens and property from terrorist attacks 
before they reach our shores.
  As Chairman of the Surface Transportation and Merchant Marine 
Subcommittee, I held several oversight hearings on transportation 
security, including one on maritime security three weeks after the 
terrible attacks of September 11. The maritime security hearing 
solidified an opinion that I, and others on the Commerce Committee, had 
long held, the need for increased maritime security was important 
before September 11, and is absolutely crucial following the terrorist

[[Page S11203]]

attacks on New York city and Washington, D.C. The Oceans, Atmosphere 
and Fisheries Subcommittee, of which I am a member, followed with 
another hearing that underscored this message. Luckily, because of the 
foresight of Chairman Hollings, we had a head start on improving 
maritime security. S. 1214, the Maritime and Port Security Improvement 
Act, of which I am a proud cosponsor, was introduced in July and was 
reported out of the Committee in August. S. 1214 establishes a regime 
that will go a long way towards creating a safe and secure maritime 
transportation system. However, since much of it was crafted before 
September 11, it is only natural that additional measures are needed to 
ensure that our maritime system is as safe as possible.
  The bill we are introducing today is based on the testimony that was 
presented at the hearings before the Commerce Committee in the first 
two weeks of October. Administration and industry witnesses testified 
on the need to improve certain areas of S. 1214. This bill intends to 
fill the gaps identified by our witnesses. We will work with Committee 
members to ensure these provisions are included in S. 1214 before the 
Senate sends it to the House.
  A constant theme following the September 11 attacks has been the need 
for better information. Testimony at our hearings confirmed this theme 
in the maritime realm, we need to increase our information collection 
capabilities immediately and we need to hold our trading partners to 
the same standards to which we hold our maritime industry. This 
legislation requires the identification of nations that have inherently 
insecure or unsafe vessel registration procedures that can pose threats 
to our national security. It requires the Secretary of Transportation 
and Secretary of State to prepare an annual report for the Congress 
that would list those nations whose vessels the Coast Guard has found 
don't play by our rules. For example, investigations by the Department 
of Transportation reveal that it is common practice for vessels to 
possess false, partial, or fraudulent information concerning cargo 
manifests, crew identity, or registration of the vessel. This 
legislation will allow us to get a handle on these practices by 
identifying the most egregious violators of maritime law. However, the 
additional information collection required by this bill is just a 
start; the bill also requires the Administration to recommend to this 
Committee additional actions that can be taken, either domestically or 
through international organizations such as the International Maritime 
Organization, that will increase the transparency of 
vessel registration procedures.

  One of the responses following the highjackings has been to 
dramatically expand the air marshal program on air carriers, a step 
which I fully support. However, there is no similar program for 
maritime vessels in U.S. waters. The Coast Guard recently established a 
sea marshal program in the port of San Francisco where armed personnel 
accompany maritime pilots aboard vessels that cause security concerns. 
This legislation expands that small project into a national sea marshal 
program to help prevent terrorists from using maritime vessels as 
weapons of mass destruction. This legislation directs the Secretary to 
analyze vulnerability of ports and place sea marshals in ports that 
handle materials or vessels that make them potential targets of attack.
  Expansion of the sea marshal program is strongly supported by our 
Nation's sea pilots. Many people do not know that almost all maritime 
vessels that enter U.S. ports are accompanied by a U.S. sea pilot that 
has intimate knowledge of port and navigational channels, a living 
nautical chart, so to speak. They are an integral part of our maritime 
system that help to keep our ports and waterways safe. Pilots are often 
the first U.S. citizen to board inbound foreign vessels and may be the 
only U.S. citizens on vessels bound for U.S. ports; thus, they can be a 
valuable source of information. This legislation requires the Secretary 
of Transportation to use them more effectively in the war on terror. 
The Secretary is directed to investigate secure and reliable methods in 
which sea pilots can aid the Coast Guard and other U.S. authorities in 
an expanded maritime domain awareness program. The pilots themselves 
came forward to this Committee suggesting this idea, and I think it is 
critical that these pilots be provided with methods and equipment that 
will allow them to safely provide the authorities with information on 
illegal or terrorist activities while there is still time to prevent a 
catastrophe. One such example is the Vessel Traffic System, VTS, in the 
Port of  New  Orleans and the excellent partnership between the Coast 
Guard and the Crescent River Pilots Association. Under this 
partnership, vessels entering port are boarded by pilots carrying 
transponders. As the vessel transits the Mississippi River, inbound and 
outbound, the operations center manned by Coast Guard and pilots know 
the exact position of the vessel, as well as the course, speed and 
other important information. While already considered a model VTS 
program, once additional transponders are acquired, this program will 
continue to serve as a template for other ports.
  This legislation also greatly improves the information collected on 
the safety and security of foreign ports. With regards to foreign 
seaport assessments, the bill aligns the authority of the Secretary of 
Transportation with authorities that currently exist for foreign 
airports. The Secretary of Transportation is required to conduct 25 
foreign port vulnerability assessments each year and to ensure that 
U.S. citizens are informed about the results of these assessments in 
advance of embarking on their travel plans. Testimony before the 
Commerce Committee emphasized that in order to ensure that our shores 
are as safe as possible, we must view foreign ports as the outer 
boundary of our ``maritime domain.'' Much as the first provision in our 
bill provides for the collection of better information on vessels and 
countries that do not follow international standards, this provision 
provides for the collection of information on foreign ports that 
present potential security threats to the United States. By requiring 
the Secretary to conduct annual assessments of 25 ports, we not only 
gain a valuable source of information, but we also put foreign ports on 
notice that they will be held responsible for actions to secure their 
ports.
  If the assessments reveal that foreign ports do not have or maintain 
adequate security measures, the President is authorized to prohibit any 
vessel, U.S. flagged or foreign, from entering the United States from 
that port. Vessels that transit unsafe and insecure ports should not be 
allowed unrestricted access to United States ports. I would like to 
remind everyone that similar security protections were enacted for 
foreign airports, and I see no reason why the President should not have 
the same powers with respect to foreign maritime ports.
  We must begin to think of a maritime security program that begins 
well before a ship enters U.S. waters and certainly before they enter 
U.S. ports. I believe that the measures in this bill along with the 
port security program of S. 1214 will provide much better tools to 
guard against maritime threats to our Nation and our citizens.
  Mr. KERRY. Madam President, As Chairman of the Oceans, Atmosphere and 
Fisheries Subcommittee, I rise today to introduce legislation to 
identify and reduce maritime threats from criminal or terrorist action, 
particularly those originating from foreign ports and vessels. I am 
particularly pleased to be joined by the Chairman of the Commerce 
Committee Mr. Hollings of South Carolina and the Chairman of the 
Surface Transportation and Merchant Marine Subcommittee Mr. Breaux of 
Louisiana.
  Senator Breaux and I recently held oversight hearings before our 
respective Subcommittees on the Coast Guard and its role in improving 
maritime security after the terrible attacks of September 11. As 
Senators Hollings and Breaux well know, even before September 11 our 
maritime and port security was in sorry shape. Senator Hollings had 
already recognized the need to rectify these deficiencies and authored 
S. 1214, the Maritime and Port Security Improvement Act, which was 
reported out of the Committee in August, and which I am proud to 
cosponsor. However, the attacks on New York and Washington made it 
clear we need to go farther afield to guard against terrorism and other 
crimes.
  Today's legislation is intended to supplement the security provisions 
of

[[Page S11204]]

S. 1214 by improving our ability to detect and prevent maritime 
terrorism and crime before it has the chance to sail into U.S. ports. 
We intend to work with Committee members to ensure these provisions are 
included in the final bill the Senate sends to the House.
  At our October 11 oversight hearing, Coast Guard Commandant James Loy 
and other witnesses gave some thoughtful testimony that is the backbone 
of this legislation. The hearing also brought to light the challenges 
presented to the Coast Guard in securing our maritime border from such 
threats. In addition to introducing this legislation, we also will 
address glaring Coast Guard resource shortfalls through increased 
authorizations in our FY 2002 Coast Guard authorization bill, which we 
will bring to the floor shortly. The Port Threat and Security Act is 
focused on giving the Coast Guard the tools and the information they 
need to do the job right.
  First, we need to improve our base of information to identify bad 
actors throughout the maritime realm. This legislation would help us 
identify those nations whose vessels and vessel registration procedures 
pose potential threats to our national security. It would require the 
Secretaries of Transportation and State to prepare an annual report for 
the Congress that would list those nations whose vessels the Coast 
Guard has found would pose a risk to our ports, or that have presented 
our government with false, partial, or fraudulent information 
concerning cargo manifests, crew identity, or registration of the 
vessel. In addition the report would identify nations that do not 
exercise adequate control over their vessel registration and ownership 
procedures, particularly with respect to security issues. We need hard 
information like this if we are to force ``flag of convenience'' 
nations from providing cover to criminals and terrorists. Mr. 
President, this is very important as Osama bin Laden has used flags of 
convenience to hide his ownership in various international shipping 
interests. In 1998 one of bin Laden's cargo freighters unloaded 
supplies in Kenya for the suicide bombers who later destroyed the 
embassies in Kenya and Tanzania. To that end, the bill requires the 
Administration to report on actions they have taken, or would 
recommend, to close these loopholes and improve transparency and 
registration procedures, either through domestic or international 
action--including action at the International Maritime Organization.

  My legislation would also establish a national Sea Marshal program to 
protect our ports from the potential use of vessels as weapons of 
terror. A Sea Marshal program was recently established in San 
Francisco, and is supported strongly by the maritime pilots who, like 
airline pilots, are on the front lines in bringing vessels into U.S. 
ports. Sea Marshals would be used in ports that handle materials that 
are hazardous or flammable in quantities that make them potential 
targets of attack. The Coast Guard took a number of steps including 
using armed Coast Guard personnel to escort a Liquid Natural Gas, LNG, 
tanker into Boston last evening. This was the first delivery of LNG to 
Boston since September 11 and a number of people were concerned about 
the safety of bringing LNG into the port. Prior to September 11 these 
vessels were escorted by Coast Guard vessels into the port but no armed 
guards were present on the vessel. I strongly believe that having armed 
personnel, such as Sea Marshals, on these high interest vessels is very 
important and will considerably increase security in our nation's 
ports, including Boston. The ability of terrorists to board a vessel 
and cause a deliberate release of LNG or gasoline for that matter is 
very real. Sea Marshals will make it much more difficult for this to 
happen. The Secretary of Transportation would be responsible for 
establishing qualifications and standards for Sea Marshals which could 
be comprised of Federal, State or local law enforcement officials.
  This legislation also aims to make use of unarmed pilots as yet 
another way to combat terrorism in our ports. Nearly every vessel that 
enters a U.S. port is first boarded by a sea pilot to assist the crew 
in navigating the harbor. Many times these pilots are the first set of 
U.S. eyes on vessels that may be headed to our ports bearing criminals 
or contraband from overseas. They are our eyes and ears, but cannot be 
expected to be a line of physical defense, that is the job of the Sea 
Marshals. This legislation would require the Secretary of 
Transportation to use these ``eyes and ears'' effectively in the war on 
terror. The Secretary is directed to investigate discrete ways in which 
sea pilots can provide information to warn of a possible terrorist 
attack or other crime. It is important that we explore secure 
mechanisms to allow these pilots to contribute to our maritime domain 
awareness, including notifying law enforcement officials of suspicious 
activity on a vessel. I am convinced there are a number of ways that 
these pilots could safely provide the authorities with information that 
can thwart illegal activities without alerting the vessel's captain or 
crew, or potential terrorists.
  This legislation would also require the Secretary of Transportation 
to conduct 25 foreign port vulnerability assessments each year, and 
places on foreign ports the same reporting and assessment requirements 
we use for foreign airports. This is essential to ensure that U.S. 
citizens are protected from harm in foreign ports, and are informed 
about any risks before leaving U.S. soil. It is also absolutely 
necessary to use foreign ports as our first defense against threats to 
U.S. ports. We cannot expect to protect U.S. borders by erecting a 
fence only at our own ports. As one of our witnesses said, ``the 
leading edge of our boundary for homeland defense is, in fact, foreign 
ports.'' In many instances, such defenses would be fruitless because of 
the sheer volume of cargo that passes through our ports daily. We need 
advance warning long before these vessels appear at our harbor 
entrances. Critical information that can help the Coast Guard identify 
these risks can only be collected at foreign ports where cargo and 
persons are first placed aboard the vessel. Despite this obvious need, 
we have fallen behind on our assessments of foreign ports. I firmly 
believe that the only way we can make U.S. ports and harbors safe is by 
going to the source and ensuring appropriate measures and facilities 
are in place to guarantee the safety of U.S. citizens visiting foreign 
ports as well as the safety of cargo bound for the United States.
  In order to pay for these inspections this legislation authorizes the 
Secretary of Transportation to collect a 50 cent user fee on all cruise 
passengers that depart the United States for a foreign port. Quite 
frankly, 50 cents is a small price to pay for the peace of mind that 
comes with knowing that a port vulnerability assessment has been 
completed prior to a cruise ship with as many as 5,000 U.S. citizens as 
passengers, docks in a particular country. U.S. citizens should not be 
disembarking in ports that have not been scrutinized for security 
violations. One witness pointed out that in many circumstances U.S. 
cruise ship passengers are passing through ports that could not be 
assessed because they were deemed too dangerous for military personnel! 
This is ludicrous. I am sure those passengers had no idea of this 
potential danger, and we need to make sure that they are both safe and 
informed.
  Lastly, this legislation would allow the President to prohibit any 
vessel, U.S. flagged or foreign, from entering the United States if the 
vessel has embarked passengers or cargo from foreign ports that do not 
have adequate security measures as determined by the Secretary of 
Transportation. Recently inspectors in Italy checking a container bound 
for Canada discovered a member of the al-Qaida terrorist organization 
hiding in a shipping container equipped with a bed and makeshift 
bathroom. The suspect, an Egyptian in a business suit, had with him a 
Canadian passport, a laptop computer, two cell phones, airport maps, 
security passes for airports in three countries and a certificate 
proclaiming him an airplane mechanic. We cannot allow any country to 
have such poor security such that terrorists can stow away in a 
shipping container. I would like to remind everyone that a similar 
provision exists in the airline industry and I see no reason why the 
President should not have the power to suspend commerce from a port 
with inadequate security, just like he can now do with international 
airports.

[[Page S11205]]

  I believe that these provisions, when combined with the strong port 
security program of S. 1214, will ensure that the United States has the 
tools, the information, and the personnel to guard against waterborne 
threats to our nation and our citizens.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1587

       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 ``Port Threat and Security 
     Act''.

     SEC. 2. IMPROVED REPORTING ON FOREIGN-FLAG VESSELS ENTERING 
                   UNITED STATES PORTS.

       Within 6 months after the date of enactment of this Act and 
     every year thereafter, the Secretary of Transportation, in 
     consultation with the Secretary of State, shall provide a 
     report to the Committees on Commerce, Science, and 
     Transportation and Foreign Relations of the Senate, and the 
     Committees on Transportation and Infrastructure and 
     International Relations of the House of Representatives that 
     lists the following information:
       (1) A list of all nations whose flag vessels have entered 
     United States ports in the previous year.
       (2) Of the nations on that list, a separate list of those 
     nations--
       (A) whose registered flag vessels appear as Priority III or 
     higher on the Boarding Priority Matrix maintained by the 
     Coast Guard;
       (B) that have presented, or whose flag vessels have 
     presented, false, intentionally incomplete, or fraudulent 
     information to the United States concerning passenger or 
     cargo manifests, crew identity or qualifications, or 
     registration or classification of their flag vessels;
       (C) whose vessel registration or classification procedures 
     have been found by the Secretary to be insufficient or do not 
     exercise adequate control over safety and security concerns; 
     or
       (D) whose laws or regulations are not sufficient to allow 
     tracking of ownership and registration histories of 
     registered flag vessels.
       (3) Actions taken by the United States, whether through 
     domestic action or international negotiation, including 
     agreements at the International Maritime Organization under 
     section 902 of the International Maritime and Port Security 
     Act (46 U.S.C. App. 1801), to improve transparency and 
     security of vessel registration procedures in nations on the 
     list under paragraph (2).
       (4) Recommendations for legislative or other actions needed 
     to improve security of United States ports against potential 
     threats posed by flag vessels of nations named in paragraph 
     (2).

     SEC. 3. SEA MARSHAL PROGRAM.

       (a) Establishment.--Within 6 months after the date of 
     enactment of this Act, the Secretary of Transportation shall 
     establish a program to place sea marshals on vessels entering 
     United States Ports identified in subsection (c).
       (b) Consultation.--In establishing this program, the 
     Secretary shall consult with representatives from the port 
     security task force and local port security committees.
       (c) Sea Marshal Ports.--The Secretary shall identify United 
     States ports for inclusion in the sea marshal program based 
     on criteria that include the following:
       (1) The presence of port facilities that handle materials 
     that are hazardous or flammable in quantities that make them 
     potential targets of attack.
       (2) The proximity of these facilities to residential or 
     other densely populated areas.
       (3) The proximity of sea lanes or navigational channels to 
     hazardous areas that would pose a danger to citizens in the 
     event of a loss of navigational control by the ship's master.
       (4) Any other criterion deemed necessary by the Secretary.
       (d) Sea Marshal Qualifications.--The Secretary shall 
     establish appropriate qualifications or standards for sea 
     marshals. The Secretary may use, or require use of, Federal, 
     State, or local personnel as sea marshals.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated to the Secretary of Transportation such 
     sums as may be necessary to carry out the requirements of 
     this section for each of the fiscal years 2002 through 2006.
       (f) Report.--Within 3 years after the date of enactment of 
     this Act, the Secretary shall report to the Committee on 
     Commerce, Science, and Transportation of the Senate, and 
     Committee on Transportation and Infrastructure of the House 
     of Representatives on the success of the program in 
     protecting the ports listed under (c), and submit any 
     recommendations.

     SEC. 4. SEA PILOT COMMUNICATION AND WARNING SYSTEM.

       Within 6 months after the date of enactment of this Act, 
     the Secretary of Transportation shall provide a secure report 
     to the Committee on Commerce, Science, and Transportation of 
     the Senate, and Committee on Transportation and 
     Infrastructure of the House of Representatives on the 
     potential for increasing the capabilities of sea pilots to 
     provide information on maritime domain awareness. The report 
     should specifically address necessary improvements to both 
     reporting procedures and equipment that could allow pilots to 
     be integrated more effectively in an maritime domain 
     awareness program.

     SEC. 5. SECURITY STANDARDS AT FOREIGN SEAPORTS.

       (a) Assessment.--
       (1) In general.--The Secretary shall assess the 
     effectiveness of the security measures maintained at--
       (A) each foreign seaport--
       (i) served by United States vessels;
       (ii) from which foreign vessels serve the United States; or
       (iii) that poses a high risk of introducing danger to 
     international sea travel; and
       (B) other foreign seaports the Secretary considers 
     appropriate.
       (2) International cooperation and standards.--The Secretary 
     of Transportation shall conduct an assessment under paragraph 
     (1) of this subsection--
       (A) in consultation with appropriate port authorities of 
     the government of a foreign country concerned and United 
     States vessel operators serving the foreign seaport for which 
     the Secretary is conducting the assessment;
       (B) to establish the extent to which a foreign seaport 
     effectively maintains and carries out security measures; and
       (C) by using a standard that will result in an analysis of 
     the security measures at the seaport based at least on the 
     standards and recommended practices of the International 
     Maritime Organization in effect on the date of the 
     assessment.
       (3) Report.--Each report to Congress required under section 
     2 shall contain a summary of the assessments conducted under 
     this subsection.
       (b) Interval.--The Secretary of Transportation shall 
     conduct assessments under subsection (a) of this section of 
     at least 25 foreign seaports annually until all seaports 
     identified in subsection (a)(1) are completed. The first 25 
     of these assessments shall be conducted within 18 months 
     after the date of enactment of this Act.
       (c) Consultation.--In carrying out subsection (a) of this 
     section, the Secretary of Transportation shall consult with 
     the Secretary of State--
       (1) on the terrorist threat that exists in each country; 
     and
       (2) to establish which foreign seaports are not under the 
     de facto control of the government of the foreign country in 
     which they are located and pose a high risk of introducing 
     danger to international sea travel.
       (d) Qualified Assessment Entities.--In carrying out 
     subsection (a) of this section, the Secretary of 
     Transportation may utilize entities determined by the 
     Secretary of Transportation and the Secretary of State to be 
     qualified to conduct such assessments.
       (e) Notifying Foreign Authorities.--If the Secretary of 
     Transportation, after conducting an assessment under 
     subsection (a) of this section, determines that a seaport 
     does not maintain and carry out effective security measures, 
     the Secretary, after advising the Secretary of State, shall 
     notify the appropriate authorities of the government of the 
     foreign country of the decision and recommend the steps 
     necessary to bring the security measures in use at the 
     seaport up to the standard used by the Secretary in making 
     the assessment.
       (f) Actions When Seaports Not Maintaining and Carrying Out 
     Effective Security Measures.--
       (1) In general.--If the Secretary of Transportation makes a 
     determination under subsection (e) that a seaport does not 
     maintain and carry out effective security measures, the 
     Secretary--
       (A) shall publish the identity of the seaport in the 
     Federal Register;
       (B) shall require the identity of the seaport to be posted 
     and displayed prominently at all United States seaports at 
     which scheduled passenger carriage is provided regularly;
       (C) shall notify the news media of the identity of the 
     seaport;
       (D) shall require each United States and foreign vessel 
     providing transportation between the United States and the 
     seaport to provide written notice of the decision, on or with 
     the ticket, to each passenger buying a ticket for 
     transportation between the United States and the seaport; and
       (E) may, after consulting with the appropriate port 
     authorities of the foreign country concerned and United 
     States and foreign vessel operators serving the seaport and 
     with the approval of the Secretary of State, withhold, 
     revoke, or prescribe conditions on the operating authority of 
     a United States or foreign vessel that uses that seaport to 
     provide foreign sea transportation.
       (2) Presidential action.--If the Secretary makes such a 
     determination under subsection (e) about a seaport, the 
     President may prohibit a United States or foreign vessel from 
     providing transportation between the United States and any 
     other foreign seaport that is served by vessels navigating to 
     or from the seaport with respect to which a decision is made 
     under this section.
       (3) When action to be taken.--
       (A) In general.--The provisions of paragraphs (1) and (2) 
     shall apply with respect to a foreign seaport--
       (i) 90 days after the government of a foreign country is 
     notified of the Secretary's determination under subsection 
     (e) of this section unless the Secretary of Transportation 
     finds that the government has

[[Page S11206]]

     brought the security measures at the seaport up to the 
     standard the Secretary used in making an assessment under 
     subsection (a) of this section before the end of that 90-day 
     period; or
       (ii) on the date on which the Secretary makes that 
     determination if the Secretary of Transportation determines, 
     after consulting with the Secretary of State, that a 
     condition exists that threatens the safety or security of 
     passengers, vessels, or crew traveling to or from the 
     seaport.
       (B) Travel advisory notification.--The Secretary of 
     Transportation immediately shall notify the Secretary of 
     State of a determination under subparagraph (A)(ii) of this 
     paragraph so that the Secretary of State may issue a travel 
     advisory required under section 908 of the International 
     Maritime and Port Security Act (46 U.S.C. App. 1804).
       (4) Congressional notification.--The Secretary of 
     Transportation promptly shall submit to Congress a report 
     (and classified annex if necessary) on action taken under 
     paragraph (1) or (2) of this subsection, including 
     information on attempts made to obtain the cooperation of the 
     government of a foreign country in meeting the standard the 
     Secretary used in assessing the seaport under subsection (a) 
     of this section.
       (5) Cancellation of publication requirements.--If the 
     Secretary of Transportation, in consultation with the 
     Secretary of State, determines that effective security 
     measures are maintained and carried out at the seaport 
     against which the Secretary took action under paragraph (1), 
     then the Secretary shall--
       (A) terminate action under paragraph (1) against that 
     seaport; and
       (B) notify the Congress of the Secretary's determination.
       (g) Suspensions.--The Secretary of Transportation, with the 
     approval of the Secretary of State and without notice or a 
     hearing, shall suspend the right of any United States vessel 
     to provide foreign sea transportation, and the right of a 
     person to operate vessels in foreign sea commerce, to or from 
     a foreign seaport if the Secretary of Transportation 
     determines that--
       (1) a condition exists that threatens the safety or 
     security of passengers, vessels, or crew traveling to or from 
     that seaport; and
       (2) the public interest requires an immediate suspension of 
     transportation between the United States and that seaport.
       (h) Authorization of Appropriations.--There are authorized 
     to be appropriated to the Secretary of Transportation 
     $2,000,000 for fiscal year 2002 and each fiscal year 
     thereafter to carry out this section.

     SEC. 6. FOREIGN PORT ASSESSMENT FEES.

       (a) In General.--The Secretary of Transportation shall 
     collect a user fee from cruise vessel lines upon the arrival 
     of a cruise vessel at a United States port from a foreign 
     port. Amounts collected under this section shall be treated 
     as offsetting collections to offset annual appropriations for 
     the costs of providing foreign port vulnerability assessments 
     under section 5.
       (b) Amount of Fee.--Cruise vessel lines shall remit $0.50 
     for each passenger embarkment on a cruise that includes at 
     least one United States port and one foreign port.
       (c) Use of Fees.--A fee collected under this section shall 
     be used solely for the costs associated with providing 
     foreign port vulnerability assessments and may be used only 
     to the extent provided in advance in an appropriation law.
       (d) Effective Date.--The requirements of this section apply 
     with respect to travel beginning more than 179 days after the 
     date of enactment of this Act.
                                 ______
                                 
      By Mr. CRAIG (for himself, Mr. Dorgan, Mr. Grassley, Mr. Baucus, 
        Mr. Crapo, Mr. Bayh, Mr. Bennett, Mr. Carper, Ms. Collins, Mr. 
        Ensign, Mr. Hollings, Mr. Hutchinson, Mr. Inhofe, Mr. Kyl, Mrs. 
        Lincoln, Mr. Murkowski, Mrs. Murray, and Mr. Smith of Oregon):
  S. 1588. A bill to provide a 1-year extension of the date for 
compliance by certain covered entities with the administrative 
simplification standards for electronic transactions and code sets 
issued in accordance with the Health Insurance Portability and 
Accountability Act of 1996; to the Committee on Finance.
  Mr. CRAIG. Mr. President, I am happy to join Senator Dorgan in 
reintroducing legislation regarding the administrative simplification 
provision of the Health Insurance Portability and Accountability Act. 
We originally introduced legislation five months ago and have worked 
since then with members from both the Finance and HELP committees to 
negotiate a compromise. The bill we are introducing today is the 
product of those discussions. It provides for one additional much-
needed year for providers, State health programs, health plans and 
others to implement the transactions and code set provision of 
administrative simplification. Importantly, this new version also 
includes language to clearly differentiate between this provision and 
the privacy provision of HIPAA. It was our intention all along that the 
medical privacy regulations not be affected by our legislation, and we 
believe this bill accomplishes that goal. My colleague and I have the 
benefit of being joined on this bill by many of the cosponsors of the 
original bill, and we are happy to have their support.
  Mr. DORGAN. Mr. President, Like Senator Craig, I appreciate the 
cooperation of our colleagues in helping us to work through this issue. 
We have arrived at a solution that is agreeable to the majority of 
parties involved, while at the same time reaching our goal of providing 
relief to small providers and plans and public health programs that are 
struggling to prepare their systems for this cost. Senator Craig and I 
would have preferred that this bill go further in providing more time 
and coordination for affected entities. On the other hand, we 
acknowledge that others would prefer no action in this area. Since we 
are just one year from the scheduled compliance date, however, we 
recognize that all those affected need some certainty as they move 
forward with complying with the transactions and code sets regulation. 
Given that this bill does provide needed relief for our states and 
given the time constraints we are facing, we believe this compromise is 
appropriate and do not feel an additional extension can be acquired.
                                 ______
                                 
      By Mr. ROCKEFELLER (for himself, Mr. Wellstone, and Mr. Baucus):
  S. 1589. A bill to amend title XVIII of the Social Security Act to 
expand medicare benefits to prevent, delay, and minimize the 
progression of chronic conditions, establish payment incentives for 
furnishing quality services to people with serious and disabling 
chronic conditions, and develop national policies on effective chronic 
condition care, and for other purposes; to the Committee on Finance.
  Mr. ROCKEFELLER. Madam President, I join several colleagues today to 
introduce the Medicare Chronic Care Improvement Act of 2001. Although 
we in Congress are focused on helping the Nation recover from the 
horrific attacks of September 11, we must also stand tall against the 
terrorists who wish to sabotage our domestic policy agenda and continue 
to work on the issues that affect the everyday health and well being of 
American citizens. With this conviction, I believe it is time to 
address the leading health care problem of the 21st century, chronic 
conditions.
  Chronic conditions account for an astounding 90 percent of morbidity, 
80 percent of deaths, and over 75 percent of direct medical 
expenditures in the United States. Nearly 125 million Americans have 
chronic conditions, and this number is expected to increase to 157 
million, approximately half the population, by 2020.
  Chronic conditions encompass an array of health conditions that are 
persistent, recurring, and cannot be cured. They include severely 
impairing conditions like Alzheimer's disease, congestive heart 
failure, chronic obstructive pulmonary disease, diabetes, depression, 
hypertension, and arthritis. Certainly in West Virginia, many of our 
workers, especially coal miners and steelworkers, suffer from chronic 
conditions.
  Treating serious and disabling chronic conditions is the highest cost 
and fastest growing segment of health care. Direct medical costs for 
chronic conditions reached $510 billion in 2000 and are projected to 
reach $1.07 trillion by 2020.
  An estimated 80 percent of Medicare beneficiaries suffer from at 
least one chronic condition and those beneficiaries account for an 
astounding 95 percent of Medicare spending. But Medicare does not 
provide many of the health care services that people with chronic 
conditions need. For example, current Medicare data show that, on 
average, people with chronic conditions see eight different physicians. 
Medicare does not compensate these physicians for communicating with 
one another, nor are they paid for care coordination, monitoring 
medications, early detection, or for educating or counseling patients 
and caregivers. As a result, few of these services, which are critical 
to people with chronic conditions, are provided.
  To meet the needs of these individuals, our health care system must 
embrace a person-centered, system-oriented approach to care. Payers and 
providers who serve the same person

[[Page S11207]]

must be empowered to work together to help people with chronic 
conditions prevent, delay, or minimize disease and disability 
progression and maximize their health and well being.
  Over 10 years ago, I served as Chairman of the Pepper Commission. Our 
final report recognized that people with chronic conditions have 
special needs requiring multidisciplinary health care or social 
services to compliment or augment their health care. The Commission 
further recognized that medical care cannot be fully accessible or 
effective for this segment of the population unless it is accompanied 
by education, outreach, and systems to coordinate a broad range of 
services. The Commission identified these needed changes over ten years 
ago. And, as I stand before you today, not a single one of these 
recommendations has been made.
  I am here to propose a long overdue and much needed solution, The 
Medicare Chronic Care Improvement Act of 2001. This bill establishes a 
comprehensive plan to update and streamline the Medicare healthcare 
delivery system to better meet the needs of people with chronic health 
conditions.
  First, the Medicare Chronic Care Improvement Act of 2001 helps 
prevent, delay, and minimize the progression of chronic conditions by 
authorizing the Secretary of Health and Human Services to expand 
coverage of preventive health benefits. The bill permits providers to 
waive deductibles and co-payments for preventive and wellness services 
and streamlines the process of approving preventive benefits.
  Second, this bill provides a person-centered, system-oriented 
approach to care for this extremely vulnerable segment of our 
population by expanding Medicare coverage to include assessment, care-
coordination, self-management services, and patient and family 
caregiver education and counseling.
  Third, this legislation improves Medicare fee-for-service and managed 
care financing for plans that serve beneficiaries with multiple, 
complex chronic conditions. The Secretary is directed to develop a plan 
to refine payment incentives to ensure appropriate payment for serving 
these high-cost individuals.
  And finally, the Medicare Chronic Care Improvement Act of 2001 
requires the Secretary of HHS to report to Congress on chronic 
condition trends and costs as a foundation for establishing national 
chronic care policies.
  For more detail, I am also entering a section-by-section bill summary 
into the Congressional Record following this statement.
  This legislation has been endorsed by a variety of health 
organizations representing consumers and providers including:
  Chronic Care Coalition, comprising the American Association of Homes 
and Services for the Aging, American Geriatrics Society, Catholic 
Health Association of the United States, Elderplan Social HMO, National 
Chronic Care Consortium, National Council on the Aging, and National 
Family Caregivers Association;
  National Depressive and Manic-Depressive Association;
  Association for Ambulatory Behavioral Healthcare; American Lung 
Association; American Academy of Neurology; American Neurological 
Association; and United Seniors Health Cooperative.
  The Medicare Chronic Care Improvement Act of 2001 provides a 
comprehensive solution to improving the quality of life and health for 
millions of Americans who are struggling with serious and disabling 
chronic conditions. It improves benefits for people with chronic 
conditions, it empowers providers to better care for these people, and 
it provides us with the research we need to better address chronic 
conditions in the future.
  And last, but not least, this legislation has the potential to save 
the Medicare program money, by better managing and treating chronic 
conditions before costly complications result. That is good for seniors 
and good for Medicare, a win-win situation. It is time to step up to 
the plate and fulfill our obligation to our Nation's most vulnerable 
citizens. This bill should stimulate the debate, and when Congress 
returns to business not related to the September 11th attacks, I intend 
to advance this legislation in the Finance Committee.
  I ask unanimous consent that the text of the bill and the summary be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1589

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Medicare 
     Chronic Care Improvement Act of 2001''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Definitions.

  TITLE I--EXPANSION OF BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE 
                   PROGRESSION OF CHRONIC CONDITIONS.

          Subtitle A--Improving Access to Preventive Services

Sec. 101. Definitions.
Sec. 102. Elimination of deductibles and coinsurance for existing 
              preventive health benefits.
Sec. 103. Institute of Medicine medicare prevention benefit study and 
              report.
Sec. 104. Authority to administratively provide for coverage of 
              additional preventive benefits.
Sec. 105. Fast-track consideration of prevention benefit legislation.

      Subtitle B--Expansion of Access to Health Promotion Services

Sec. 111. Disease self-management demonstration projects.
Sec. 112. Medicare health education and risk appraisal program.

  Subtitle C--Medicare Coverage for Care Coordination and Assessment 
                                Services

Sec. 121. Care coordination and assessment services.

  TITLE II--PAYMENT INCENTIVES FOR QUALITY CARE FOR INDIVIDUALS WITH 
                SERIOUS AND DISABLING CHRONIC CONDITIONS

Sec. 201. Adjustments to fee-for-service payment systems.
Sec. 202. Medicare+Choice.

   TITLE III--DEVELOPMENT OF NATIONAL POLICIES ON EFFECTIVE CHRONIC 
                             CONDITION CARE

Sec. 301. Study and report on effective chronic condition care.
Sec. 302. Institute of Medicine medicare chronic condition care 
              improvement study and report.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Secretary.--Unless otherwise specifically provided, the 
     term ``Secretary'' means the Secretary of Health and Human 
     Services.
       (2) Serious and disabling chronic condition.--The term 
     ``serious and disabling chronic condition'' means, with 
     respect to an individual, that the individual has at least 
     one physical or mental condition and a licensed health care 
     practitioner has certified within the preceding 12-month 
     period that--
       (A) the individual has a level of disability such that the 
     individual is unable to perform (without substantial 
     assistance from another individual) for a period of at least 
     90 days due to a loss of functional capacity--
       (i) at least 2 activities of daily living; or
       (ii) such number of instrumental activities of daily living 
     that is equivalent (as determined by the Secretary) to the 
     level of disability described in clause (i);
       (B) the individual has a level of disability equivalent (as 
     determined by the Secretary) to the level of disability 
     described in subparagraph (A); or
       (C) the individual requires substantial supervision to 
     protect the individual from threats to health and safety due 
     to severe cognitive impairment.
       (3) Activities of daily living.--The term ``activities of 
     daily living'' means each of the following:
       (A) Eating.
       (B) Toileting.
       (C) Transferring.
       (D) Bathing.
       (E) Dressing.
       (F) Continence.
       (4) Instrumental activities of daily living.--The term 
     ``instrumental activities of daily living'' means each of the 
     following:
       (A) Medication management.
       (B) Meal preparation.
       (C) Shopping.
       (D) Housekeeping.
       (E) Laundry.
       (F) Money management.
       (G) Telephone use.
       (H) Transportation use.

  TITLE I--EXPANSION OF BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE 
                   PROGRESSION OF CHRONIC CONDITIONS.

          Subtitle A--Improving Access to Preventive Services

     SEC. 101. DEFINITIONS.

       In this title:
       (1) Cost-effective benefit.--The term ``cost-effective 
     benefit'' means a benefit or technique that has--
       (A) been subject to peer review;
       (B) been described in scientific journals; and
       (C) demonstrated value as measured by unit costs relative 
     to health outcomes achieved.

[[Page S11208]]

       (2) Cost-saving benefit.--The term ``cost-saving benefit'' 
     means a benefit or technique that has--
       (A) been subject to peer review;
       (B) been described in scientific journals; and
       (C) caused a net reduction in health care costs for 
     medicare beneficiaries.
       (3) Medically effective.--The term ``medically effective'' 
     means, with respect to a benefit or technique, that the 
     benefit or technique has been--
       (A) subject to peer review;
       (B) described in scientific journals; and
       (C) determined to achieve an intended goal under normal 
     programmatic conditions.
       (4) Medically efficacious.--The term ``medically 
     efficacious'' means, with respect to a benefit or technique, 
     that the benefit or technique has been--
       (A) subject to peer review;
       (B) described in scientific journals; and
       (C) determined to achieve an intended goal under controlled 
     conditions.

     SEC. 102. ELIMINATION OF DEDUCTIBLES AND COINSURANCE FOR 
                   EXISTING PREVENTIVE HEALTH BENEFITS.

       (a) In General.--Section 1833 of the Social Security Act 
     (42 U.S.C. 1395l) is amended by inserting after subsection 
     (o) the following new subsection:
       ``(p) Deductibles and Coinsurance Waived for Preventive 
     Health Items and Services.--The Secretary shall not require 
     the payment of any deductible or coinsurance under subsection 
     (a) or (b), respectively, of any individual enrolled for 
     coverage under this part for any of the following preventive 
     health items and services:
       ``(1) Blood-testing strips, lancets, and blood glucose 
     monitors for individuals with diabetes described in section 
     1861(n).
       ``(2) Diabetes outpatient self-management training services 
     (as defined in section 1861(qq)(1)).
       ``(3) Pneumococcal, influenza, and hepatitis B vaccines and 
     administration described in section 1861(s)(10).
       ``(4) Screening mammography (as defined in section 
     1861(jj)).
       ``(5) Screening pap smear and screening pelvic exam (as 
     defined in paragraphs (1) and (2) of section 1861(nn), 
     respectively).
       ``(6) Bone mass measurement (as defined in section 
     1861(rr)(1)).
       ``(7) Prostate cancer screening test (as defined in section 
     1861(oo)(1)).
       ``(8) Colorectal cancer screening test (as defined in 
     section 1861(pp)(1)).
       ``(9) Screening for glaucoma (as defined in section 
     1861(uu)).
       ``(10) Medical nutrition therapy services (as defined in 
     section 1861(vv)(1)).''.
       (b) Waiver of Coinsurance.--
       (1) In general.--Section 1833(a)(1)(B) of the Social 
     Security Act (42 U.S.C. 1395l(a)(1)(B)) is amended to read as 
     follows: ``(B) with respect to preventive health items and 
     services described in subsection (p), the amounts paid shall 
     be 100 percent of the fee schedule or other basis of payment 
     under this title for the particular item or service,''.
       (2) Elimination of coinsurance in outpatient hospital 
     settings.--The third sentence of section 1866(a)(2)(A) of the 
     Social Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by 
     inserting after ``1861(s)(10)(A)'' the following: ``, 
     preventive health items and services described in section 
     1833(p),''.
       (c) Waiver of Application of Deductible.--Section 
     1833(b)(1) of the Social Security Act (42 U.S.C. 1395l(b)(1)) 
     is amended to read as follows: ``(1) such deductible shall 
     not apply with respect to preventive health items and 
     services described in subsection (p),''.
       (d) Adding ``Lancet'' to Definition of DME.--Section 
     1861(n) of the Social Security Act (42 U.S.C. 1395x(n)) is 
     amended by striking ``blood-testing strips and blood glucose 
     monitors'' and inserting ``blood-testing strips, lancets, and 
     blood glucose monitors''.
       (e) Conforming Amendments.--
       (1) Elimination of coinsurance for clinical diagnostic 
     laboratory tests.--Paragraphs (1)(D)(i) and (2)(D)(i) of 
     section 1833(a) of the Social Security Act (42 U.S.C. 
     1395l(a)), as amended by section 201(b)(1) of the Medicare, 
     Medicaid, and SCHIP Benefits Improvement and Protection Act 
     of 2000 (114 Stat. 2763A-481), as enacted into law by section 
     1(a)(6) of Public Law 106-554, are each amended by inserting 
     ``or which are described in subsection (p)'' after 
     ``assignment-related basis''.
       (2) Elimination of coinsurance for certain dme.--Section 
     1834(a)(1)(A) of the Social Security Act (42 U.S.C. 
     1395m(a)(1)(A)) is amended by inserting ``(or 100 percent, in 
     the case of such an item described in section 1833(p))'' 
     after ``80 percent''.
       (3) Elimination of deductibles and coinsurance for 
     colorectal cancer screening tests.--Section 1834(d) of the 
     Social Security Act (42 U.S.C. 1395m(d)) is amended--
       (A) in paragraph (2)(C)--
       (i) by striking ``(C) Facility payment limit.--'' and all 
     that follows through ``Notwithstanding subsections'' and 
     inserting the following:
       ``(C) Facility payment limit.--Notwithstanding 
     subsections'';
       (ii) by striking ``(I) in accordance'' and inserting the 
     following:
       ``(i) in accordance'';
       (iii) by striking ``(II) are performed'' and all that 
     follows through ``payment under'' and inserting the 
     following:
       ``(ii) are performed in an ambulatory surgical center or 
     hospital outpatient department,
     payment under''; and
       (iv) by striking clause (ii); and
       (B) in paragraph (3)(C)--
       (i) by striking ``(C) Facility payment limit.--'' and all 
     that follows through ``Notwithstanding subsections'' and 
     inserting the following:
       ``(C) Facility payment limit.--Notwithstanding 
     subsections''; and
       (ii) by striking clause (ii).
       (f) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after the day that is 
     1 year after the date of enactment of this Act.

     SEC. 103. INSTITUTE OF MEDICINE MEDICARE PREVENTION BENEFIT 
                   STUDY AND REPORT.

       (a) Study.--
       (1) In general.--The Secretary shall contract with the 
     Institute of Medicine of the National Academy of Sciences 
     to--
       (A) conduct a comprehensive study of current literature and 
     best practices in the field of health promotion and disease 
     prevention among medicare beneficiaries, including the issues 
     described in paragraph (2); and
       (B) submit the report described in subsection (b).
       (2) Issues studied.--The study required under paragraph (1) 
     shall include an assessment of--
       (A) whether each health promotion and disease prevention 
     benefit covered under the medicare program is--
       (i) medically effective (as defined in section 101(3)); or
       (ii) a cost-effective benefit (as defined in section 
     101(1)) or a cost-saving benefit (as defined in section 
     101(2));
       (B) utilization by medicare beneficiaries of such benefits 
     (including any barriers to or incentives to increase 
     utilization);
       (C) quality of life issues associated with such benefits; 
     and
       (D) whether health promotion and disease prevention 
     benefits that are not covered under the medicare program that 
     would affect all medicare beneficiaries are--
       (i) likely to be medically effective (as defined in section 
     101(3)); or
       (ii) likely to be a cost-effective benefit (as defined in 
     section 101(1)) or a cost-saving benefit (as defined in 
     section 101(2));
       (b) Reports.--
       (1) Three-year report.--On the date that is 3 years after 
     the date of enactment of this Act, and each successive 3-year 
     anniversary thereafter, the Institute of Medicine of the 
     National Academy of Sciences shall submit to the President a 
     report that contains--
       (A) a detailed statement of the findings and conclusions of 
     the study conducted under subsection (a); and
       (B) the recommendations for legislation described in 
     paragraph (3).
       (2) Interim report based on new guidelines.--If the United 
     States Preventive Services Task Force or the Task Force on 
     Community Preventive Services establishes new guidelines 
     regarding preventive health benefits for medicare 
     beneficiaries more than 1 year prior to the date that a 
     report described in paragraph (1) is due to be submitted to 
     the President, then not later than 6 months after the date 
     such new guidelines are established, the Institute of 
     Medicine of the National Academy of Sciences shall submit to 
     the President a report that contains a detailed description 
     of such new guidelines. Such report may also contain 
     recommendations for legislation described in paragraph (3).
       (3) Recommendations for legislation.--The Institute of 
     Medicine of the National Academy of Sciences, in consultation 
     with the United States Preventive Services Task Force and the 
     Task Force on Community Preventive Services, shall develop 
     recommendations in legislative form that--
       (A) prioritize the preventive health benefits under the 
     medicare program; and
       (B) modify such benefits, including adding new benefits 
     under such program, based on the study conducted under 
     subsection (a).
       (c) Transmission to Congress.--
       (1) In general.--Subject to paragraph (2), on the day that 
     is 6 months after the date on which the report described in 
     paragraph (1) of subsection (b) (or paragraph (2) of such 
     subsection if the report contains recommendations in 
     legislative form described in subsection (b)(3)) is submitted 
     to the President, the President shall transmit the report and 
     recommendations to Congress.
       (2) Regulatory action by the secretary of health and human 
     services.--If the Secretary of Health and Human Services has 
     exercised the authority under section 104(a) to adopt by 
     regulation one or more of the recommendations under 
     subsection (b)(3), the President shall only submit to 
     Congress those recommendations under subsection (b)(3) that 
     have not been adopted by the Secretary.
       (3) Delivery.--Copies of the report and recommendations in 
     legislative form required to be transmitted to Congress under 
     paragraph (1) shall be delivered--
       (A) to both Houses of Congress on the same day;
       (B) to the Clerk of the House of Representatives if the 
     House is not in session; and
       (C) to the Secretary of the Senate if the Senate is not in 
     session.

     SEC. 104. AUTHORITY TO ADMINISTRATIVELY PROVIDE FOR COVERAGE 
                   OF ADDITIONAL PREVENTIVE BENEFITS.

       (a) In General.--The Secretary of Health and Human Services 
     may by regulation adopt any or all of the legislative 
     recommendations developed by the Institute of Medicine of the 
     National Academy of Sciences, in consultation with the United

[[Page S11209]]

     States Preventive Services Task Force and the Task Force on 
     Community Preventive Services in a report under section 
     103(b)(3) (relating to prioritizing and modifying preventive 
     health benefits under the medicare program and the addition 
     of new preventive benefits), consistent with subsection (b).
       (b) Elimination of Cost-Sharing.--With respect to items and 
     services furnished under the medicare program that the 
     Secretary has incorporated by regulation under subsection 
     (a), the provisions of section 1833(p) of the Social Security 
     Act (relating to elimination of cost-sharing for preventive 
     benefits), as added by section 102(a), shall apply to those 
     items and services in the same manner as such section applies 
     to the items and services described in paragraphs (1) through 
     (10) of such section.
       (c) Deadline.--The Secretary must publish a notice of 
     rulemaking with respect to the adoption by regulation under 
     subsection (a) of any such recommendation within 6 months of 
     the date on which a report described in section 103(b) is 
     submitted to the President.

     SEC. 105. FAST-TRACK CONSIDERATION OF PREVENTION BENEFIT 
                   LEGISLATION.

       (a) Rules of House of Representatives and Senate.--This 
     section is enacted by Congress--
       (1) as an exercise of the rulemaking power of the House of 
     Representatives and the Senate, respectively, and is deemed a 
     part of the rules of each House of Congress, but--
       (A) is applicable only with respect to the procedure to be 
     followed in that House of Congress in the case of an 
     implementing bill (as defined in subsection (d)); and
       (B) supersedes other rules only to the extent that such 
     rules are inconsistent with this section; and
       (2) with full recognition of the constitutional right of 
     either House of Congress to change the rules (so far as 
     relating to the procedure of that House of Congress) at any 
     time, in the same manner and to the same extent as in the 
     case of any other rule of that House of Congress.
       (b) Introduction and Referral.--
       (1) Introduction.--
       (A) In general.--Subject to paragraph (2), on the day on 
     which the President transmits the report pursuant to section 
     103(c) to the House of Representatives and the Senate, the 
     recommendations in legislative form transmitted by the 
     President with respect to such report shall be introduced as 
     a bill (by request) in the following manner:
       (i) House of representatives.--In the House of 
     Representatives, by the Majority Leader, for himself and the 
     Minority Leader, or by Members of the House of 
     Representatives designated by the Majority Leader and 
     Minority Leader.
       (ii) Senate.--In the Senate, by the Majority Leader, for 
     himself and the Minority Leader, or by Members of the Senate 
     designated by the Majority Leader and Minority Leader.
       (B) Special rule.--If either House of Congress is not in 
     session on the day on which such recommendations in 
     legislative form are transmitted, the recommendations in 
     legislative form shall be introduced as a bill in that House 
     of Congress, as provided in subparagraph (A), on the first 
     day thereafter on which that House of Congress is in session.
       (2) Referral.--Such bills shall be referred by the 
     presiding officers of the respective Houses to the 
     appropriate committee, or, in the case of a bill containing 
     provisions within the jurisdiction of 2 or more committees, 
     jointly to such committees for consideration of those 
     provisions within their respective jurisdictions.
       (c) Consideration.--After the recommendations in 
     legislative form have been introduced as a bill and referred 
     under subsection (b), such implementing bill shall be 
     considered in the same manner as an implementing bill is 
     considered under subsections (d), (e), (f), and (g) of 
     section 151 of the Trade Act of 1974 (19 U.S.C. 2191).
       (d) Implementing Bill Defined.--In this section, the term 
     ``implementing bill'' means only the recommendations in 
     legislative form of the Institute of Medicine of the National 
     Academy of Sciences described in section 103(b)(3), 
     transmitted by the President to the House of Representatives 
     and the Senate under subsection 103(c), and introduced and 
     referred as provided in subsection (b) as a bill of either 
     House of Congress.
       (e) Counting of Days.--For purposes of this section, any 
     period of days referred to in section 151 of the Trade Act of 
     1974 shall be computed by excluding--
       (1) the days on which either House of Congress is not in 
     session because of an adjournment of more than 3 days to a 
     day certain or an adjournment of Congress sine die; and
       (2) any Saturday and Sunday, not excluded under paragraph 
     (1), when either House is not in session.

      Subtitle B--Expansion of Access to Health Promotion Services

     SEC. 111. DISEASE SELF-MANAGEMENT DEMONSTRATION PROJECTS.

       (a) Demonstration Projects.--
       (1) In general.--The Secretary shall conduct demonstration 
     projects for the purpose of promoting disease self-management 
     for conditions identified, and appropriately prioritized, by 
     the Secretary for target individuals (as defined in paragraph 
     (2)).
       (2) Target individual defined.--In this section, the term 
     ``target individual'' means an individual who--
       (A) is at risk for, or has, 1 or more of the conditions 
     identified by the Secretary as being appropriate for disease 
     self-management; and
       (B) is entitled to benefits under part A of title XVIII of 
     the Social Security Act (42 U.S.C. 1395c et seq.), or 
     enrolled under part B of such title ( 42 U.S.C. 1395j et 
     seq.) or is enrolled under the Medicare+Choice program under 
     part C of such title (42 U.S.C. 1395w-21 et seq.).
       (b) Number; Project Areas; Duration.--
       (1) Number.--Not later than 2 years after the date of 
     enactment of this Act, the Secretary shall implement a series 
     of demonstration projects to carry out the purpose described 
     in subsection (a)(1).
       (2) Project areas.--The Secretary shall implement the 
     demonstration projects described in paragraph (1) in urban, 
     suburban, and rural areas.
       (3) Duration.--The demonstration projects under this 
     section shall be conducted during the 3-year period beginning 
     on the date on which the initial demonstration project is 
     implemented.
       (c) Report to Congress.--
       (1) In general.--Not later than 18 months after the 
     conclusion of the demonstration projects under this section, 
     the Secretary shall submit a report to Congress on such 
     projects.
       (2) Contents of report.--The report required under 
     paragraph (1) shall include the following:
       (A) A description of the demonstration projects.
       (B) An evaluation of--
       (i) whether each benefit provided under the demonstration 
     projects is--

       (I) medically effective;
       (II) medically efficacious;
       (III) cost-effective; or
       (IV) cost-saving;

       (ii) the level of the disease self-management attained by 
     target individuals under the demonstration projects; and
       (iii) the satisfaction of target individuals under the 
     demonstration projects.
       (C) Recommendations of the Secretary regarding whether to 
     conduct the demonstration projects on a permanent basis.
       (D) Such recommendations for legislation and administrative 
     action as the Secretary determines to be appropriate.
       (E) Any other information regarding the demonstration 
     projects that the Secretary determines to be appropriate.
       (d) Funding.--The Secretary shall provide for the transfer 
     from the Federal Hospital Insurance Trust Fund under section 
     1817 of the Social Security Act (42 U.S.C. 1395i) an amount 
     not to exceed $30,000,000 for the costs of carrying out this 
     section.

     SEC. 112. MEDICARE HEALTH EDUCATION AND RISK APPRAISAL 
                   PROGRAM.

       Title XVIII of the Social Security Act (42 U.S.C. 1395 et 
     seq.) is amended by adding at the end the following new 
     section:


         ``medicare health education and risk appraisal program

       ``Sec. 1897. (a) Establishment.--Not later than 18 months 
     after the date of the conclusion of the demonstration 
     projects conducted under subsection (b)(1), the Secretary 
     shall establish a comprehensive and systematic model for 
     delivering health promotion and disease prevention services 
     that--
       ``(1) through self-assessment identifies--
       ``(A) behavioral risk factors, such as tobacco use, 
     physical inactivity, alcohol use, depression, lack of proper 
     nutrition, and risk of falling, among target individuals;
       ``(B) needed medicare clinical preventive and screening 
     health benefits among target individuals; and
       ``(C) functional and self-management information the 
     Secretary determines to be appropriate;
       ``(2) provides ongoing followup to reduce risk factors and 
     promote the appropriate use of preventive and screening 
     health benefits;
       ``(3) improves clinical outcomes, satisfaction, quality of 
     life, and appropriate use by target individuals of items and 
     services covered under the medicare program; and
       ``(4) provides target individuals with information 
     regarding the adoption of healthy behaviors.
       ``(b) Demonstration Projects.--
       ``(1) Establishment.--Not later than 1 year after the date 
     of enactment of this section, the Secretary, in consultation 
     with the Director of the Centers for Disease Control and 
     Prevention, and the Director of the Agency for Healthcare 
     Research and Quality, shall conduct demonstration projects 
     for the purpose of developing a comprehensive and systematic 
     model for delivering health promotion and disease prevention 
     services described in subsection (a).
       ``(2) Self-assessment and provision of information.--The 
     Secretary shall conduct the demonstration projects 
     established under paragraph (1) in the following manner:
       ``(A) Self-assessment.--
       ``(i) In general.--The Secretary shall test different--

       ``(I) methods of making self-assessments available to each 
     target individual;
       ``(II) methods of encouraging each target individual to 
     participate in the self-assessment; and
       ``(III) methods for processing responses to the self-
     assessment.

       ``(ii) Contents.--A self-assessment made available under 
     clause (i) shall include--

       ``(I) questions regarding behavioral risk factors;
       ``(II) questions regarding needed preventive screening 
     health services;
       ``(III) questions regarding the target individual's 
     preferences for receiving follow-up information; and

[[Page S11210]]

       ``(IV) other information that the Secretary determines 
     appropriate.

       ``(B) Provision of information.--After each target 
     individual completes the self-assessment, the Secretary shall 
     ensure that the target individual is provided with such 
     information as the Secretary determines appropriate, which 
     may include--
       ``(i) information regarding the results of the self-
     assessment;
       ``(ii) recommendations regarding any appropriate behavior 
     modification based on the self-assessment;
       ``(iii) information regarding how to access behavior 
     modification assistance that promotes healthy behavior, 
     including information on nurse hotlines, counseling services, 
     provider services, and case-management services;
       ``(iv) information, feedback, support, and recommendations 
     regarding any need for clinical preventive and screening 
     health services or treatment; and
       ``(v) referrals to available community resources in order 
     to assist the target individual in reducing health risks.
       ``(3) Project areas and duration.--
       ``(A) Project areas.--The Secretary shall implement the 
     demonstration projects in geographic areas that include 
     urban, suburban, and rural areas.
       ``(B) Duration.--The Secretary shall conduct the 
     demonstration projects during the 3-year period beginning on 
     the date on which the first demonstration project is 
     implemented.
       ``(c) Report to Congress.--
       ``(1) In general.--Not later than 1 year after the date on 
     which the demonstration projects conclude, the Secretary 
     shall submit to Congress a report on such projects.
       ``(2) Contents of report.--The report submitted under 
     paragraph (1) shall--
       ``(A) describe the demonstration projects conducted under 
     this section;
       ``(B) identify the demonstration project that is the most 
     effective; and
       ``(C) contain such other information regarding the 
     demonstration projects as the Secretary determines 
     appropriate.
       ``(3) Measurement of effectiveness.--For purposes of 
     paragraph (2)(B), in identifying the demonstration project 
     that is the most effective, the Secretary shall consider--
       ``(A) how successful the project was at--
       ``(i) reaching target individuals and engaging them in an 
     assessment of the risk factors of such individuals;
       ``(ii) educating target individuals on healthy behaviors 
     and getting such individuals to modify their behaviors in 
     order to diminish the risk of chronic disease; and
       ``(iii) ensuring that target individuals were provided with 
     necessary information;
       ``(B) the cost-effectiveness of the demonstration project; 
     and
       ``(C) the degree of beneficiary satisfaction under the 
     demonstration projects.
       ``(d) Waiver Authority.--The Secretary may waive such 
     requirements under this title as the Secretary determines 
     necessary to carry out the demonstration projects under this 
     section.
       ``(e) Funding.--There are authorized to be appropriated 
     $25,000,000 to the Secretary for carrying out the 
     demonstration projects under this section.
       ``(f) Definition of Target Individual.--The term `target 
     individual' means each individual who is--
       ``(1) entitled to benefits under part A or enrolled under 
     part B, including an individual enrolled under the 
     Medicare+Choice program under part C; or
       ``(2) between the ages of 50 and 64 and who is not 
     described in paragraph (1).''.

  Subtitle C--Medicare Coverage for Care Coordination and Assessment 
                                Services

     SEC. 121. CARE COORDINATION AND ASSESSMENT SERVICES.

       (a) Services Authorized.--Title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.), as amended by section 
     112, is further amended by adding at the end the following 
     new section:


              ``care coordination and assessment services

       ``Sec. 1898. (a) Purpose.--The purpose of this section is 
     to provide assistance to a beneficiary with a serious and 
     disabling chronic condition (as defined in subsection (f)(1)) 
     to obtain the appropriate level and mix of follow-up care.
       ``(b) Election of Care Coordination and Assessment 
     Services.--
       ``(1) In general.--On or after January 1, 2003, a 
     beneficiary with a serious and disabling chronic condition 
     may elect to receive care coordination services in accordance 
     with the provisions of this section under which, in 
     appropriate circumstances, the eligible beneficiary has 
     health care services covered under this title managed and 
     coordinated by a care coordinator who is qualified under 
     subsection (e) to furnish care coordination services under 
     this section.
       ``(2) Revocation of election.--An eligible beneficiary who 
     has made an election under paragraph (1) may revoke that 
     election at any time.
       ``(c) Outreach.--The Secretary shall provide for the wide 
     dissemination of information to beneficiaries and providers 
     of services, physicians, practitioners, and suppliers with 
     respect to the availability of and requirements for care 
     coordination services under this section.
       ``(d) Care Coordination and Assessment Services 
     Described.--Care coordination services under this section 
     shall include the following:
       ``(1) Basic care coordination and assessment services.--
       ``(A) In general.--Except as otherwise provided in this 
     section, eligible beneficiaries who have made an election 
     under this section shall receive the following services:
       ``(i)(I) An initial assessment of an individual's medical 
     condition, functional and cognitive capacity, and 
     environmental and psychosocial needs.
       ``(II) Annual assessments after the initial assessment 
     performed under subclause (I), unless the physician or care 
     coordinator of the individual determines that additional 
     assessments are required due to sentinel health events or 
     changes in the health status of the individual that may 
     require changes in plans of care developed for the 
     individual.
       ``(ii) The development of an initial plan of care, and 
     subsequent appropriate revisions to that plan of care.
       ``(iii) The management of, and referral for, medical and 
     other health services, including multidisciplinary care 
     conferences and coordination with other providers.
       ``(iv) The monitoring and management of medications.
       ``(v) Patient education and counseling services.
       ``(vi) Family caregiver education and counseling services.
       ``(vii) Self-management services, including health 
     education and risk appraisal to identify behavioral risk 
     factors through self-assessment.
       ``(viii) Providing access for consultations by telephone 
     with physicians and other appropriate health care 
     professionals, including 24-hour availability of such 
     professionals for emergency consultations.
       ``(ix) Coordination with the principal nonprofessional 
     caregiver in the home.
       ``(x) Managing and facilitating transitions among health 
     care professionals and across settings of care, including the 
     following:

       ``(I) Pursuing the treatment option elected by the 
     individual.
       ``(II) Including any advance directive executed by the 
     individual in the medical file of the individual.

       ``(xi) Activities that facilitate continuity of care and 
     patient adherence to plans of care.
       ``(xii) Information about, and referral to, hospice 
     services, including patient and family caregiver education 
     and counseling about hospice, and facilitating transition to 
     hospice when elected.
       ``(xiii) Such other medical and health care services for 
     which payment would not otherwise be made under this title as 
     the Secretary determines to be appropriate for effective care 
     coordination, including the additional items and services as 
     described in subparagraph (B).
       ``(B) Additional benefits.--The Secretary may specify 
     additional benefits for which payment would not otherwise be 
     made under this title that may be available to eligible 
     beneficiaries who have made an election under this section 
     (subject to an assessment by the care coordinator of an 
     individual beneficiary's circumstances and need for such 
     benefits) in order to encourage the receipt of, or to improve 
     the effectiveness of, care coordination services.
       ``(2) Care coordination and assessment requirement.--
     Notwithstanding any other provision of this title, with 
     respect to items and services for which payment is made under 
     this title furnished to a beneficiary for the diagnosis and 
     treatment of the beneficiary's serious and disabling chronic 
     condition, if the beneficiary has made an election to receive 
     care coordination and assessment services under this section, 
     the Secretary may require that payment may only be made under 
     this title for such items and services relating to such 
     condition if the items and services have been furnished by or 
     coordinated through the care coordinator. Under such 
     provision, the Secretary shall prescribe exceptions for 
     emergency medical services (as described in section 
     1852(d)(3), but without regard to enrollment with a 
     Medicare+Choice organization), and other exceptions 
     determined by the Secretary for the delivery of timely and 
     needed care.
       ``(e) Care Coordinators.--
       ``(1) Conditions of participation.--In order to be 
     qualified to furnish care coordination and assessment 
     services under this section, an individual or entity shall--
       ``(A) be a health care professional or entity (which may 
     include physicians, physician group practices, or other 
     health care professionals or entities the Secretary may find 
     appropriate) meeting such conditions as the Secretary may 
     specify;
       ``(B) enter into a care coordination agreement under 
     paragraph (2); and
       ``(C) meet such criteria as the Secretary may establish 
     (which may include experience in the provision of care 
     coordination or primary care physician's services).
       ``(2) Agreement term; payment.--
       ``(A) Duration and renewal.--A care coordination agreement 
     under this subsection shall--
       ``(i) be entered into for a period of 1 year and may be 
     renewed if the Secretary is satisfied that the care 
     coordinator continues to meet the conditions of participation 
     specified in paragraph (1);
       ``(ii) assure the compliance of the care coordinator with 
     such data collection and reporting requirements as the 
     Secretary determines necessary to assess the effect of care 
     coordination on health outcomes; and

[[Page S11211]]

       ``(iii) contain such other terms and conditions as the 
     Secretary may require.
       ``(B) Payment for services.--The Secretary shall establish 
     payment terms and conditions and payment rates for basic care 
     coordination and assessment services described in subsection 
     (d)(1). The Secretary may establish new billing codes to 
     carry out the provisions of this subparagraph.
       ``(f) Definitions.--In this section:
       ``(1) Serious and disabling chronic condition.--The term 
     `serious and disabling chronic condition' means, with respect 
     to an individual, that the individual has at least one 
     physical or mental condition and a licensed health care 
     practitioner has certified within the preceding 12-month 
     period that--
       ``(A) the individual has a level of disability such that 
     the individual is unable to perform (without substantial 
     assistance from another individual) for a period of at least 
     90 days due to a loss of functional capacity--
       ``(i) at least 2 activities of daily living; or
       ``(ii) such number of instrumental activities of daily 
     living that is equivalent (as determined by the Secretary) to 
     the level of disability described in clause (i);
       ``(B) the individual has a level of disability equivalent 
     (as determined by the Secretary) to the level of disability 
     described in subparagraph (A); or
       ``(C) the individual requires substantial supervision to 
     protect the individual from threats to health and safety due 
     to severe cognitive impairment.
       ``(2) Activities of daily living.--The term `activities of 
     daily living' means each of the following:
       ``(A) Eating.
       ``(B) Toileting.
       ``(C) Transferring.
       ``(D) Bathing.
       ``(E) Dressing.
       ``(F) Continence.
       ``(3) Instrumental activities of daily living.--The term 
     `instrumental activities of daily living' means each of the 
     following:
       ``(A) Medication management.
       ``(B) Meal preparation.
       ``(C) Shopping.
       ``(D) Housekeeping.
       ``(E) Laundry.
       ``(F) Money management.
       ``(G) Telephone use.
       ``(H) Transportation use.
       ``(4) Beneficiary.--The term `beneficiary' means an 
     individual entitled to benefits under part A, or enrolled 
     under part B, including an individual enrolled under the 
     Medicare+Choice program under part C.''.
       (b) Coverage of Care Coordination and Assessment Services 
     as a Part B Medical Service.--
       (1) In general.--Section 1861(s) of the Social Security Act 
     (42 U.S.C. 1395x(s)) is amended--
       (A) in the second sentence, by redesignating paragraphs 
     (16) and (17) as clauses (i) and (ii); and
       (B) in the first sentence--
       (i) by striking ``and'' at the end of paragraph (14);
       (ii) by striking the period at the end of paragraph (15) 
     and inserting ``; and''; and
       (iii) by adding after paragraph (15) the following new 
     paragraph:
       ``(16) care coordination and assessment services furnished 
     by a care coordinator in accordance with section 1866C.''.
       (2) Conforming amendments.--Sections 1864(a) 1902(a)(9)(C), 
     and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 1395aa(a), 
     1396a(a)(9)(C), and 1396n(a)(1)(B)(ii)(I)) are each amended 
     by striking ``paragraphs (16) and (17)'' each place it 
     appears and inserting ``clauses (i) and (ii) of the second 
     sentence''.
       (3) Part b coinsurance and deductible not applicable to 
     care coordination and assessment services.--
       (A) Coinsurance.--Section 1833(a)(1) of the Social Security 
     Act (42 U.S.C. 1395l(a)(1)), as amended by sections 105 and 
     223 of the Medicare, Medicaid, and SCHIP Benefits Improvement 
     and Protection Act of 2000, as enacted into law by section 
     1(a)(6) of Public Law 106-554, is amended--
       (i) by striking ``and'' at the end of subparagraph (T); and
       (ii) by inserting before the final semicolon ``, and (V) 
     with respect to care coordination and assessment services 
     described in section 1861(s)(16) that are furnished by, or 
     coordinated through, a care coordinator, the amounts paid 
     shall be 100 percent of the payment amount established under 
     section 1866C''.
       (B) Deductible.--Section 1833(b) of such Act (42 U.S.C. 
     1395l(b)) is amended--
       (i) by striking ``and'' at the end of paragraph (5); and
       (ii) by inserting before the final period ``, and (7) such 
     deductible shall not apply with respect to care coordination 
     and assessment services (as described in section 
     1861(s)(16))''.
       (C) Elimination of coinsurance in outpatient hospital 
     settings.--The third sentence of section 1866(a)(2)(A) of 
     such Act (42 U.S.C. 1395cc(a)(2)(A)), as amended by section 
     102(b)(2), is further amended by inserting after ``section 
     1833(p),'' the following: ``with respect to care coordination 
     and assessment services (as described in section 
     1861(s)(16)),''.

  TITLE II--PAYMENT INCENTIVES FOR QUALITY CARE FOR INDIVIDUALS WITH 
                SERIOUS AND DISABLING CHRONIC CONDITIONS

     SEC. 201. ADJUSTMENTS TO FEE-FOR-SERVICE PAYMENT SYSTEMS.

       (a) In General.--The Secretary of Health and Human Services 
     shall provide for appropriate adjustments to each of the 
     payment systems described in subsection (b) to take into 
     account the additional costs incurred in providing items and 
     services under the medicare program to medicare beneficiaries 
     who suffer from serious and disabling chronic conditions, 
     including the consideration of the patient classification 
     system (or other methodology) under subsection (d). The 
     Secretary shall implement such adjustments for items and 
     services furnished on or after October 1, 2005.
       (b) Payment Systems Described.--The payment systems 
     referred to in subsection (a) are the following:
       (1) The prospective payment system for covered skilled 
     nursing facility services under section 1888(e) of such Act 
     (42 U.S.C. 1395yy(e)).
       (2) The prospective payment system for home health services 
     under section 1895 of such Act (42 U.S.C. 1395fff).
       (3) The prospective payment system for outpatient hospital 
     services under section 1833(t) of such Act (42 U.S.C. 
     1395l(t)).
       (4) The physician fee schedule under section 1848 of such 
     Act (42 U.S.C. 1395w-4).
       (5) The composite rate of payment for dialysis services 
     under section 1881(b)(7) of such Act (42 U.S.C. 
     1395rr(b)(7)).
       (6) The payment rate for outpatient therapy services and 
     comprehensive outpatient rehabilitation services under 
     section 1834(k) of such Act (42 U.S.C. 1395m(k)).
       (7) The payment rate for partial hospitalization services 
     established by the Secretary in regulations under title XVIII 
     of such Act.
       (8) The payment rate for hospice services under section 
     1814(i) of such Act (42 U.S.C. 1395f(i)).
       (c) Interim Report.--Not later than 18 months after the 
     date of enactment of this Act, the Secretary shall submit to 
     Congress a report on the proposed adjustments required under 
     subsection (a) to the payment systems described in subsection 
     (b), the methodology employed by the Secretary in providing 
     for such proposed adjustments, and an assessment of the 
     impact of such adjustments on access to effective care for 
     medicare beneficiaries.
       (d) Patient Classification System.--The Secretary shall 
     develop a patient classification system or other methodology 
     to predict costs within and across postacute care settings 
     attributable to furnishing items and services to medicare 
     beneficiaries who suffer from serious and disabling chronic 
     conditions. The Secretary shall develop such system by not 
     later than October 1, 2004, and shall consult with 
     representatives of providers of services and individuals with 
     expertise in health care financing and risk adjustment 
     methodology in developing such system.

     SEC. 202. MEDICARE+CHOICE.

       (a) Revisions to Risk Adjustment Methodology.--
       (1) In general.--The Secretary shall revise the risk 
     adjustment methodology under section 1853(a)(3) of the Social 
     Security Act (42 U.S.C. 1395w-23(a)(3)) applicable to 
     payments to Medicare+Choice organizations offering 
     specialized programs for frail elderly and at-risk 
     beneficiaries to take into account variations in costs 
     incurred by such organizations.
       (2) Methods considered.--In revising the risk adjustment 
     methodology under paragraph (1), the Secretary shall 
     consider--
       (A) hybrid risk adjustment payment systems, such as partial 
     capitation;
       (B) new diagnostic and service markers that more accurately 
     predict high risk;
       (C) improving the structural components of the applicable 
     method of payment, such as reducing payment lag, using 
     multiple site diagnostic data, and using several years of 
     data;
       (D) providing for adjustments to payment amounts for 
     beneficiaries with comorbidities;
       (E) testing concurrent risk adjustment methodologies; and
       (F) testing payment methods using data from specialized 
     programs for frail elderly and at-risk beneficiaries.
       (3) Implementation.--The Secretary shall implement such 
     revisions to the risk adjustment methodology for items and 
     services furnished on or after January 1, 2005.
       (4) Interim report.--Not later than January 1, 2004, the 
     Secretary shall submit to Congress a report on revision of 
     the risk adjustment methodology required under paragraph (1), 
     including a description of the methods considered and 
     employed by the Secretary in providing for such revision and 
     an assessment of the impacts of such methods on access to 
     effective care for medicare beneficiaries.
       (b) Interim Continuation of Blended Rate for Specialized 
     Programs for Frail Elderly and At-Risk Medicare Beneficiaries 
     Residing in Institutions.--
       (1) In general.--In the case of a Medicare+Choice 
     organization that complies with the requirements under 
     paragraph (2) and that offers a Medicare+Choice plan that 
     provides for a specialized program for frail elderly and at-
     risk beneficiaries that exclusively serves beneficiaries in 
     institutions or beneficiaries that are entitled to medical 
     assistance under a State plan under title XIX, 
     notwithstanding section 1853(a)(3)(C)(ii) of the Social 
     Security Act (42 U.S.C. 1395w-23(a)(3)(C)(ii)), such 
     organization shall be paid according to the method described 
     in section 1853(a)(3)(C)(ii)(I) until such time as

[[Page S11212]]

     the Secretary has implemented the revised risk adjustment 
     methodology required in subsection (a).
       (2) Requirements.--A Medicare+Choice organization may not 
     qualify for the payment methodology under paragraph (1) 
     unless the organization collects such data (and in such 
     format) as the Secretary requires to monitor quality of 
     services provided, outcomes, and costs, including functional 
     and diagnostic data and information collected through the 
     Health Outcomes Survey.
       (c) Interim Continuation of Payment Methodologies for 
     Demonstration Programs.--
       (1) In general.--Notwithstanding any other provision of 
     law, payment methodologies for medicare demonstration 
     programs for specialized programs for frail elderly and at-
     risk beneficiaries that comply with the requirements under 
     paragraph (2) shall continue under the terms and conditions 
     of the demonstration authority, including the risk adjustment 
     factors and formula used for paying such demonstration 
     programs, until such time as the Secretary has implemented 
     the revised risk adjustment methodology required in 
     subsection (a).
       (2) Requirements.--A medicare demonstration program may not 
     qualify for the payment methodology under paragraph (1) 
     unless the program collects such data (and in such format) as 
     the Secretary requires to monitor quality of services 
     provided, outcomes, and costs, including functional and 
     diagnostic data and information collected through the Health 
     Outcomes Survey.
       (d) Interim Demonstration Program for Additional Payments 
     for Specialized Programs.--
       (1) In general.--The Secretary shall establish a 
     demonstration program under which additional payments (in 
     such manner and amount as the Secretary determines 
     appropriate) may be made to a Medicare+Choice organization 
     that complies with the requirements under paragraph (2) and 
     that offers a Medicare+Choice plan that--
       (A) provides, directly or through contract, for a 
     specialized program of care for enrollees with serious and 
     disabling chronic conditions; and
       (B) exclusively serves enrollees with serious and disabling 
     chronic conditions or serves a disproportionate share of such 
     enrollees.
       (2) Requirements.--A Medicare+Choice organization may not 
     qualify for additional payments under paragraph (1) unless 
     the organization and the specialized program of care meet the 
     following requirements:
       (A) Under the specialized program of care, a clinical 
     delivery system is established that meets the needs of such 
     enrollees, including--
       (i) methods to prevent, delay, or minimize the progression 
     of disabilities;
       (ii) disease management protocols, such as high risk 
     screening to identify risk of hospitalization, nursing home 
     placement, functional decline, death, and other factors that 
     increase the costs of care provided;
       (iii) appropriate specially trained health care staff, such 
     as nurse practitioners, geriatric care managers, or mental 
     health professionals; and
       (iv) methods for promoting integration of care, financing, 
     and administrative functions across health care settings.
       (B) The organization collects such data (and in such 
     format) as the Secretary requires to monitor quality of 
     services provided, outcomes, and costs, including functional 
     and diagnostic data and information collected through the 
     Health Outcomes Survey.
       (C) The organization employs quality standards and tracks 
     quality indicators specified by the Secretary that are 
     relevant to the special needs of enrollees with serious and 
     disabling chronic conditions.
       (D) The organization does not receive payments, or 
     adjustment to payments, with respect to any enrollee by 
     reason of subsection (b) or (c).
       (3) Waiver authority.--The Secretary may waive such 
     requirements of title XVIII of the Social Security Act as may 
     be necessary to carry out this demonstration program.
       (4) Termination.--The demonstration program under this 
     subsection shall terminate 1 year after such time as the 
     Secretary has implemented the revised risk adjustment 
     methodology required in subsection (a).
       (5) Funding.--There are authorized to be appropriated to 
     the Secretary $25,000,000 for carrying out the demonstration 
     program under this subsection.
       (e) Definition.--In this section, the term ``specialized 
     programs for frail elderly and at-risk beneficiaries'' 
     means--
       (1) demonstrations approved by the Secretary for purposes 
     of testing the integration of acute and expanded care 
     services under prepaid financing which include prescription 
     drugs and other noncovered ancillary services, care 
     coordination, and home and community-based services, such as 
     the social health maintenance organization demonstration 
     project authorized under section 2355 of the Deficit 
     Reduction Act of 1984 and expanded under section 
     4207(b)(4)(B)(i) of the Omnibus Reconciliation Act of 1990;
       (2) demonstrations approved by the Secretary for purposes 
     of improving quality of care and preventing hospitalizations 
     for nursing home residents, such as the EverCare 
     demonstration project;
       (3) demonstrations approved by the Secretary for purposes 
     of testing methods for integrating medicare and medicaid 
     benefits for the dually eligible, such as the Minnesota 
     Senior Health Options program, the Wisconsin Partnership 
     program, the Massachusetts Senior Care Organization program, 
     and the Rochester Community Care Network program;
       (4) demonstrations approved by the Secretary under 
     subsection (d); and
       (5) such other demonstrations or programs approved by the 
     Secretary for similar purposes, as determined by the 
     Secretary.

   TITLE III--DEVELOPMENT OF NATIONAL POLICIES ON EFFECTIVE CHRONIC 
                             CONDITION CARE

     SEC. 301. STUDY AND REPORT ON EFFECTIVE CHRONIC CONDITION 
                   CARE.

       (a) Study.--For purposes of improving chronic condition 
     care furnished to medicare beneficiaries under the medicare 
     program, the Secretary of Health and Human Services shall 
     conduct a comprehensive study of chronic condition trends of 
     medicare beneficiaries and associated service utilization, 
     quality indicators, and cumulative costs.
       (b) Specific Matters Studied.--The study conducted under 
     subsection (a) shall include an assessment of the following:
       (1) Chronic condition prevalence rates.
       (2) Demographic, medical, and functional information about 
     medicare beneficiaries with chronic conditions.
       (3) Utilization, cost, and quality data across settings, 
     including--
       (A) expenditures under a State plan under title XIX of the 
     Social Security Act for individuals dually eligible for 
     benefits under the medicare and medicaid programs,
       (B) data on out-of-pocket expenses paid by medicare 
     beneficiaries,
       (C) data on payments made by non-Federal health insurance 
     programs,
       (D) amounts and percentages of overall payments made to 
     medicare providers of services and suppliers for medicare 
     beneficiaries with chronic conditions, and
       (E) current and future cost-shifting for treatment of such 
     beneficiaries between the medicare and medicaid programs.
       (c) Information.--
       (1) In general.--The Secretary may collect such data from 
     providers of services, suppliers, fiscal intermediaries, and 
     carriers. Such providers, suppliers, fiscal intermediaries, 
     and carriers shall furnish to the Secretary the data the 
     Secretary requires to conduct the study under subsection (a).
       (2) Requirement to consider data previously collected.--To 
     the maximum extent practicable, in conducting the study, the 
     Secretary shall analyze existing data and utilize existing 
     data collection methodologies.
       (3) Consultation.--The Secretary shall consult with 
     representatives of providers of services, suppliers, fiscal 
     intermediaries, and carriers with respect to data collection 
     requirements to conduct the study with respect to the 
     specific matters described in subsection (b).
       (d) Report.--
       (1) In general.--Not later than 3 years after the date of 
     enactment of this Act, and triennially thereafter, the 
     Secretary shall submit to Congress a report on the study 
     conducted under subsection (a) and the specific matters 
     studied under subsection (b).
       (2) Recommendations.--Each report shall also include 
     specific recommendations with respect to appropriate care for 
     medicare beneficiaries with chronic conditions, including the 
     establishment, and refinement, of goals for reducing chronic 
     condition prevalence rates and related medical expenses.
       (e) Definition.--In this section, the term ``chronic 
     condition'' means one or more physical or mental conditions 
     which are likely to last for an unspecified period of time, 
     or for the duration of an individual's life, for which there 
     is no known cure, and which may affect an individual's 
     ability to carry out basic activities of daily living, 
     instrumental activities of daily living, or both.
       (f) Reduction of Paperwork; Assistance With Development of 
     Computer-Assisted Paperwork Reduction Technology.--
       (1) Reduction of paperwork.--Not later than one year after 
     the date of enactment of this Act, the Secretary shall, in 
     consultation with providers of services and suppliers under 
     the medicare program, patient advocacy groups, and State and 
     local health care administration experts, implement a program 
     to eliminate or simplify those paperwork requirements that 
     are not required by law, and do not contribute to the quality 
     of care furnished to medicare beneficiaries or the integrity 
     of the medicare program.
       (2) Development of best practices software.--
       (A) In general.--The Secretary, through the Office of 
     Research and Development of the Center for Medicare and 
     Medicaid Services, shall develop and disseminate to providers 
     of services and suppliers participating in the medicare 
     program best practices electronic software and medical 
     technology information systems designed to reduce the 
     duplicative recording of information, to reduce the need for 
     handwritten entries, and to reduce the risk of medical and 
     pharmaceutical errors in data entry.
       (B) Technical assistance.--The Secretary shall provide for 
     technical assistance in the use of the electronic software 
     developed under subparagraph (A).
       (C) Authorization of appropriations.--For each of fiscal 
     years 2002, 2003, and 2004, there are authorized to be 
     appropriated to the Secretary $10,000,000 to carry out this 
     paragraph.

     SEC. 302. INSTITUTE OF MEDICINE MEDICARE CHRONIC CONDITION 
                   CARE IMPROVEMENT STUDY AND REPORT.

       (a) Study.--

[[Page S11213]]

       (1) In general.--The Secretary shall contract with the 
     Institute of Medicine of the National Academy of Sciences 
     to--
       (A) conduct a comprehensive study of the medicare program 
     to identify--
       (i) factors that facilitate access to effective care 
     (including, where appropriate, hospice care) for medicare 
     beneficiaries with chronic conditions; and
       (ii) factors that impede access to such care for such 
     beneficiaries,
     including the issues studied under paragraph (2); and
       (B) submit the report described in subsection (b).
       (2) Issues studied.--The study required under paragraph (1) 
     shall--
       (A) identify inconsistent clinical, financial, or 
     administrative requirements across provider and supplier 
     settings or professional services with respect to medicare 
     beneficiaries;
       (B) identify requirements under the program imposed by law 
     or regulation that--
       (i) promote costshifting across providers and suppliers;
       (ii) impede access to effective chronic condition care by 
     requiring the demonstration of continuing clinical 
     improvement of the condition as a prerequisite to coverage of 
     certain benefits;
       (iii) impose unnecessary burdens on such beneficiaries and 
     their family caregivers;
       (iv) impede coverage for services that prevent, delay, or 
     minimize the progression of chronic conditions;
       (v) impede the establishment of administrative information 
     systems to track health status, utilization, cost, and 
     quality data across providers and suppliers and provider 
     settings;
       (vi) impede the establishment of clinical information 
     systems that support continuity of care across settings and 
     over time;
       (vii) impede the alignment of financial incentives among 
     the medicare program, the medicaid program, and group health 
     plans and providers and suppliers that furnish services to 
     the same beneficiary; or
       (viii) impede payment methods that encourage the enrollment 
     of high-risk populations, support innovation, or encourage 
     providers and suppliers to maintain or improve health status 
     for such medicare beneficiaries.
       (b) Report.--On the date that is 18 months after the date 
     of enactment of this Act, the Institute of Medicine of the 
     National Academy of Sciences shall submit to Congress and the 
     Secretary of Health and Human Services a report that 
     contains--
       (1) a detailed statement of the findings and conclusions of 
     the study conducted under subsection (a); and
       (2) recommendations to improve access to effective care for 
     medicare beneficiaries with chronic conditions.
                                  ____


      Summary of the Medicare Chronic Care Improvement Act of 2001


  title I--expansion of benefits to prevent, delay, and minimize the 
                   progression of chronic conditions

                 Improve access to preventive services

       Eliminate deductibles and co-insurance for Medicare covered 
     preventive services.
       Streamline process of approving preventive benefits by 
     directing the Secretary of Health and Human Services to 
     contract with the Institute of Medicine (IOM) to investigate 
     and recommend new preventive benefits every 3 years. Grant 
     the Secretary the authority to implement these 
     recommendations, and fast-track the recommendations through 
     Congress if the Secretary chooses not to act upon this 
     authority.

               Expand access to health promotion services

       Establish demonstration projects to promote disease self-
     management.
       Implement a Medicare health education and risk appraisal 
     program no later than 18 months after a series of 
     demonstration projects conclude.

     Expand coverage for care coordination and assessment services

       Create a new benefit that covers assessment, care 
     coordination, counseling, and education assistance for 
     individuals with serious and disabling chronic conditions. 
     Services could be provided by health care professionals, 
     including physicians, social workers, and nurses.
       Examples of items and services to be covered include: 
     initial and periodic health screening and assessments; 
     management and referral for medical and other health 
     services; medication management; and patient and family 
     caregiver education and counseling.


title ii--establish payment incentives for furnishing quality services 
      to individuals with serious and disabling chronic conditions

                   Improve medicare financing methods

       Direct the Secretary to refine Medicare prospective payment 
     systems for skilled nursing facility (SNF), home health, 
     therapy, partial hospitalization, end stage renal dialysis 
     (ESRD), and outpatient hospital services and refine resource-
     based relative value scale (RBRVS) payment methods for 
     physicians to ensure appropriate payment for serving 
     individuals with serious and disabling chronic conditions.
       Direct the Secretary to refine Medicare+Choice risk 
     adjustment methodology to provide adequate payment for plans 
     with specialized programs for frail elderly and at-risk 
     beneficiaries.
       Until the refined risk adjustment methodology is 
     implemented, direct the Secretary to continue current payment 
     methodologies for existing specialized programs for frail 
     elderly and at-risk beneficiaries.
       Create a demonstration program to provide additional 
     payments to Medicare+Choice plans that provide a specialized 
     program of care for beneficiaries with serious and disabling 
     chronic conditions. These plans must exclusively serve such 
     beneficiaries or serve a disproportionate share of such 
     beneficiaries. The demonstration program would expire one 
     year after the refund risk adjustment methodology is 
     implemented.


    Title III--Study and Report on Effective Chronic Condition Care

      Evaluate Medicare policies regarding chronic condition care

       Direct the Secretary to study chronic condition trends and 
     associated service utilization, cumulative costs, and quality 
     indicators in Medicare.
       Direct the Secretary to report the study results to 
     Congress every 3 years. The report must include 
     recommendations on improving care for Medicare beneficiaries 
     with chronic conditions, reducing chronic conditions, and 
     reducing related medical expenses.

Identify improvements in Medicare to ensure effective chronic condition 
                                  care

       Direct the Secretary to contract with the IOM to 
     investigate and identify barriers and facilitators to 
     effective care for Medicare beneficiaries with chronic 
     conditions, including inconsistent clinical, financial, or 
     administrative requirements across care settings. The IOM's 
     report must include recommendations to improve access to 
     effective care.

                              Definitions

       ``Chronic condition'' means one or more physical or mental 
     conditions which are likely to last for an unspecified period 
     of time, or for the duration of an individual's life, for 
     which there is no known cure, and which may affect an 
     individual's ability to carry out basic activities of daily 
     living (ADLs), instrumental activities of daily living 
     (IADLs), or both.
       ``Serious and disabling chronic condition(s)'' means the 
     individual has one or more physical or mental conditions and 
     has been certified by a licensed health care practitioner 
     within the preceding 12 months as having a level of 
     disability such that the individual, for at least 90 days, is 
     unable to perform at least 2 ADLs or a number of IADLs or 
     other measure indicating an equivalent level of disability or 
     requiring substantial supervision due to severe cognitive 
     impairment.
                                 ______
                                 
      By Mr. NELSON of Florida:
  S. 1592. A bill to amend title XI of the Social Security Act to 
prohibit Federal funds from being used to provide payments under a 
Federal health care program to any health care provider who charges a 
membership or any other extraneous or incidental fee to a patient as a 
prerequisite for the provision of an item or services to the patient; 
to the Committee on Finance.
  Mr. NELSON of Florida. Mr. President, I am pleased to introduce the 
Medicare Equal Access to Care Act. I am jointed by my colleagues 
Senators Durbin and Edwards. This legislation is designed to address a 
disturbing development which may make it harder for some seniors to 
have access to Medicare.
  I have recently become aware of a practice, an early example if which 
took place in Florida, in which doctors assess their existing patients 
a $1,500 membership fee in order to receive continued care. In some 
States, these fees have been as high as $20,000. By charging these 
extraneous and unwarranted dues, the doctors can shrink their practice, 
yet maintain their profits. Another version of this arrangement is to 
require that patients seek and pay for non-Medicare covered services 
from their doctors as a condition for joining or remaining in the 
practice. Tragically, the patients who can't afford these large sums 
for the privilege of medical care or who choose not to purchase non-
Medicare covered services are simply told to find another doctor. In 
areas where there is already a shortage of doctors, this practice could 
severely hamper Medicare beneficiaries' access to health care.
  Then, in addition to membership fees the doctors bill Medicare for 
the cost of the covered services they provide.
  Were Medicare a private insurance company, this practice would not be 
allowed. Private health insurance companies do not permit their 
providers to charge an ``access fee'' as a condition to being accepted 
as a patient. The Federal Government, the American taxpayers, should 
not hold its providers to a looser standard, thereby supporting a 
distasteful division of Medicare beneficiaries into haves and have-
nots. This situation is unacceptable.

[[Page S11214]]

  The Medicare Equal Access to Care Act bill will put a damper on such 
agreements. This legislation is simple: it will prevent any federal 
health program, like Medicare, from reimbursing doctors who charge 
their patients membership fees, as defined by the Secretary of Health 
and Human Services, or who require that their patients purchase non-
Medicare.
  I want to emphasize that this legislation does not interfere with the 
right of the doctor and patient to enter into private arrangements. A 
doctor may forego Medicare reimbursement and charge patients a 
membership fee of any amount, and patients have the choice of whether 
to accept that condition. Likewise, a doctor is free to charge a 
patient for any service that is not reimbursed under Medicare.
  Though they present a carefully crafted loophole, these arrangements 
violate the intent and spirit of the Balanced Billing Act.
  Clearly, our health care system is not working for patients. 
Additionally it's not working for doctors, if they must resort to these 
types of practices. Also, hundreds of thousands of our nation's seniors 
have been informed that their managed care company will be withdrawing 
from the Membership program. We need to adequately reimburse doctors, 
to provide the incentive to continue to participate in the 
Medicare+Choice program. Just as we don't want Medicare beneficiaries 
to be told their HMO is unavailable, we don't want them to be told 
their doctor is unavailable, unless they pay a fee. These are among 
these reasons that Congress needs to complete and pass a Patient's Bill 
of Rights and send it to the President. But in the meantime, we must 
protect our seniors and ensure that their access to Medicare is not 
subject to hurdles and conditions.
  I look forward to working with my colleagues to pass the Medicare 
Equal Access to Care Act.
  I ask unanimous consent that the text of the Bill be printed in the 
Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1592

       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 ``Equal Access to Care Act''.

     SEC. 2. LIMITATION ON PAYMENTS TO PROVIDERS UNDER A FEDERAL 
                   HEALTH CARE PROGRAM.

       (a) In General.--Title XI of the Social Security Act (42 
     U.S.C. 1301 et seq.) is amended by inserting after section 
     1128F the following new section:

     ``SEC. 1128G. LIMITATION ON PAYMENTS TO PROVIDERS UNDER A 
                   FEDERAL HEALTH CARE PROGRAM.

       ``(a) In General.--No Federal funds shall be used to 
     provide payments under a Federal health care program to any 
     physician (as defined in section 1861(r)), practitioner (as 
     described in section 1842(b)(18)(C)), or other individual who 
     charges a membership fee or any other extraneous or 
     incidental fee to a patient, or requires a patient to 
     purchase an item or service, as a prerequisite for the 
     provision of an item or service to the patient.
       ``(b) Federal Health Care Program Defined.--In this 
     section, the term `Federal health care program' has the 
     meaning given that term under section 1128B(f) except that, 
     for purposes of this section, such term includes the health 
     insurance program under chapter 89 of title 5, United States 
     Code.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     applies to payments made on or after the date of enactment of 
     this Act.
                                 ______
                                 
      By Mr. JEFFORDS (for himself, Mr. Smith of New Hampshire, and Mr. 
        Crapo):
  S. 1593. A bill to authorize the Administrator of the Environmental 
Protection Agency to establish a grant program to support research 
projects on critical infrastructure protection for water supply 
systems, and for other purposes; to the Committee on Environment and 
Public Works.
  Mr. JEFFORDS. Mr. President, Members of the Senate, I rise before you 
today to introduce the Water Infrastructure Security and Research 
Development Act. This legislation authorizes the U.S. Environmental 
Protection Agency to provide funding to support research projects on 
critical infrastructure protection for water supply systems.
  Our Nation's water supply system is truly unique. It uses a 
decentralized, community-based approach to provide superior water 
services to all citizens of the United States. Here, we turn on the tap 
in our homes and receive clean, fresh water without giving it much 
thought. This not the way water systems operate throughout the world.
  A 1997 United Nations report on the state of water resources 
worldwide states that at least one-fifth of all people do not have 
access to safe drinking water, and more than one-half lack adequate 
sanitation. Quoting from the report:

       The World Health Organization estimates that a total of 
     more than five million people die each year just from 
     diseases caused by unsafe drinking water, and a lack of 
     sanitation and water for hygiene. Provision of safe drinking 
     water and sanitation could reduce the amount of illness and 
     death by as much as three-quarters, depending on the disease.

  In this country, we often take our water system for granted. When 
considered in the international context, the true value of our water 
system becomes more apparent. We truly have something to protect.
  During my tenure as Chairman of the Environment and Public Works 
Committee, we have been evaluating the state of our Nation's water 
infrastructure, both drinking water and wastewater. It is clear that we 
have work to do to modernize our existing systems and ensure that we 
continue to provide clean, safe water to our citizens into the future. 
Our discussions in the Committee tend to focus on infrastructure 
replacement needs, the funds that will be required, and the extent of 
the federal role. I am committed to this process, and I look forward to 
continuing to work with my colleagues on legislation that we plan to 
introduce early next year.
  However, today, I rise to speak to you about another aspect of our 
Nation's water infrastructure--security. Since the events of September 
11, I have worked with the members of the Environment and Public Works 
Committee and the Environmental Protection Agency to ensure that we are 
taking the steps necessary to protect our nation's water infrastructure 
system during these times. There are many short term actions that have 
already been taken.
  Based on the recommendations of Presidential Decision Directive 63, 
issued by President Clinton in 1998, the Environmental Protection 
Agency and its industry partner, the Association of Metropolitan Water 
Agencies, have established a communications system, a water 
infrastructure Information Sharing and Analysis Center, designed to 
provide real-time threat assessment data to water utilities throughout 
the nation.
  Through this partnership, the Environmental Protection Agency and the 
Association of Metropolitan Water Agencies are working to develop 
generic assessment tools that individual water utilities can use to 
assess their facilities for potential physical and cyber threats. I 
believe that the rapid completion of both these tools and the 
individual assessments is imperative. In early October, I sent a letter 
to the President with Senators Smith, Graham, and Crapo and 
Representatives Tauzin, Dingell, Gillmor, and Pallone requesting that 
he use a portion of the $20 billion of discretionary funds provided to 
the Administration by Congress this year to provide assistance for 
these assessments to water utilities.
  The legislation I am introducing today with Senator Smith will take 
us one step further by authorizing support of both ongoing efforts 
under Presidential Decision Directive 63 and new research to assess 
potential threats to our water supply system and develop solutions.
  This legislation authorizes twelve million dollars per year from 2002 
to 2007 for the Environmental Protection Agency to use for grants to or 
cooperative agreements with research institutions. Projects conducted 
under these agreements will be used to conduct research addressing 
physical and cyber threats at water supply systems, improvements in 
information sharing and analysis efforts, and technical assistance and 
training. These projects will address both drinking water and 
wastewater systems that make up our nation's water supply 
infrastructure.

[[Page S11215]]

  Eligible research institutions will include public and private 
entities, including national laboratories that perform research that 
will improve the security of water supply systems. Our legislation 
includes a provision to ensure that those entities conducting this 
research have the ability to effectively safeguard sensitive 
information.
  Individual projects will fall into a series of categories designed to 
develop the information we need to protect our water supply system 
nationwide.
  First, projects will assess the security issues for water supply 
systems by conducting assessments and developing and refining 
vulnerability assessment tools.
  Second, projects will protect water supply systems from potential 
threats by developing technologies, processes, guidelines, standards, 
and procedures for the purpose of protecting water supply systems. 
Projects will also develop real-time monitoring systems to protect 
against chemical, biological, or radiological attack.
  Third, projects will develop technologies and processes for 
addressing the mitigation, response and recovery of biological, 
chemical and radiological contamination of water supply systems.
  Fourth, projects will implement requirements of Presidential Decision 
Directive 63 by refining and operating the Information Sharing and 
Analysis Center to capture and share threats, events and best 
practices.
  Finally, projects will test and evaluate new technologies and 
processes by developing regional ``pilot facilities'' to demonstrate 
upgraded security systems, assess new technologies, and to determine 
operational and cost impacts due to enhanced security.
  Individual awards may not exceed one million dollars. Test and 
evaluation projects will be cost-shared on a 50-50 basis.
  I look forward to working with my colleagues on this legislation and 
other efforts to enhance the security of our Nation's water 
infrastructure in the weeks, months, and years to come. We truly have 
something to protect; clean, safe, fresh water is worth our investment.
                                 ______
                                 
      By Mrs. CLINTON (for herself, Mr. Smith of Oregon, Mr. Kennedy, 
        and Mrs. Murray):
  S. 1594. A bill to amend the Public Health Service Act to provide 
programs to improve nurse retention, the nursing workplace, and the 
quality of care; to the Committee on Health, Education, Labor, and 
Pensions.
  Mrs. CLINTON. Mr. President, I am proud to introduce today the Nurse 
Retention and Quality Care Act of 2001 and to speak about the 
importance of nurses and the work they do. On September 11, nurses were 
among those who were on the front lines of the battle against 
terrorism. With courage, skill and determination, they were on the job, 
treating the injured, helping to save lives.
  To this day, nurses are defending America. In clinics, hospitals and 
offices around the country, they are working to detect and treat actual 
or suspected cases of anthrax. Should our Nation face other biological 
threats or terrorist attacks, nurses will be there for us.
  Today's news that a woman who works in the Manhattan Eye, Ear and 
Throat Hospital is in critical condition with possible inhalation 
anthrax is a reminder of the hazards faced by health care workers. And 
it is a reminder of how important it is that our public health system 
be fully staffed with trained health care professionals.
  Sadly, America is facing a nursing shortage at a time when the need 
for more nurses is so clear. Our nurses are facing an emergency of 
their own and they need our help. The nursing shortage imposes 
increasing hardship on hospitals and nurses alike, and threatens the 
ability of our health care system to provide basic patient care, much 
less respond to health crises and terrorism.
  Not only is the number of individuals entering the nursing profession 
falling, but hospitals are also facing difficulty retaining the nurses 
already on staff. Fifty percent of nurses say they have recently 
considered leaving their jobs for reasons other than retirement, and 
approximately half a million licensed nurses are not currently 
practicing nursing. Many of the nurses who have considered leaving the 
profession cite their low level of overall job satisfaction.
  While we must do more to improve the number of nurses in training, we 
must also take steps to enhance the workplace to retain current nurses, 
and that is what the bill that Senator Gordon Smith and I will be 
introducing today would address.
  One way to retain nurses is to follow the example of those hospitals 
that have become nursing ``magnets.'' They are successful because they 
involve nurses in decision-making, encourage collaboration among health 
professionals, give nurses the opportunity to pursue continuing 
education and advancement, and they organize care to improve patient 
outcome.
  Our bill is designed to encourage more hospitals to follow these 
leads. And I am pleased that hospitals and nurses support this bill. It 
has been endorsed by the American Nurses Association and the American 
Hospitals Association.
  It is also a good bill for patients and their quality of care as 
well. Research has shown that magnet hospitals have lower mortality 
rates, shorter lengths of stay, higher patient satisfaction and cost-
efficiency.
  As our Nation faces increasing threats of terrorist and biological 
attack, our health system must be stronger than ever before. One of the 
best ways we can do this is by taking steps to reverse the nursing 
shortage, and ensure that nurses on the front lines are well-prepared 
to respond to emergencies.
  Our bill does both. First, it creates demonstration programs to 
encourage states to adopt magnet hospital practices, which will help 
attract and retain the nursing staff our hospitals need so they can 
cope with surges in patient volume.
  And, second, our bill encourages nurses to pursue continued 
education. That is so important today, when we need more health care 
professionals who can detect the early signs of a bioterrorist attack. 
This legislation will promote the kind of training that the New York 
State Nurses Association, Bellevue Hospital and New York College 
provide for nurses in my state.
  Mr. SMITH of Oregon. Mr. President, I rise today to join my colleague 
from New York, Senator Clinton, in introducing the Nurse Retention and 
Quality of Care Act of 2001. As most of my colleagues already know, our 
Nation is facing an unprecedented nursing shortage. A Northwest Health 
Foundation study released this year found that Oregon alone will have 
3,200 nursing vacancies in 2010. It is critical that we act immediately 
to address this shortage, and we must start by retaining the highly 
skilled nurses that already constitute the foundation of our health 
care system.
  Our Nation's nursing shortage is not merely the result of poor nurse 
recruitment, this shortage exists in large part because nurses are 
leaving the profession altogether. Half a million licensed nurses are 
not currently practicing. These nurses represent some of our Nation's 
most compassionate and experienced health care professionals, but they 
feel compelled to look elsewhere for work, and we must do something to 
change this disturbing trend.
  The Nurse Retention and Quality of Care Act will give hospitals 
incentives to develop and implement model practices for retaining 
nurses, such as the methods used by ``magnet hospitals''. Magnet 
hospitals have been in existence for a number of years, and share 
certain characteristics designed to make these hospitals attractive 
workplaces for nurses. These hospitals promote nurse participation in 
decision-making, collaboration and communication among health care 
professionals, opportunities for nurses to pursue education and career 
advancement, and a balanced and accommodating work environment for 
nurses.
  Nurses in magnet hospitals stay twice as long on average as those in 
non-magnet hospitals, and consistently report greater job satisfaction. 
Patients also express higher satisfaction in magnet hospitals. There is 
one such hospital in my home state of Oregon, Providence St. Vincent 
Medical Center in Portland, OR, and I am not alone in hoping this 
legislation will lead to additional magnet facilities. Our legislation 
will authorize $40 million in demonstration grants for health care 
facilities to implement the model practices

[[Page S11216]]

utilized by magnet hospitals, and I believe that this will be an 
important step toward fixing our Nation's impending nursing shortage.
  Nurses are the human face of medicine, but the demands on them are 
increasingly difficult to bear. The Nurse Retention and Quality of Care 
Act paves the way for hospitals to implement practices that will 
improve the morale of nurses and encourage them to stay in the nursing 
profession. Now, more than ever, with the current health and safety 
concerns facing our Nation, we must let nurses know that they are 
important to us and that we value their expertise and compassion. By 
passing this bill, we can do just that, and take important steps to 
ensure an adequate supply of highly qualified nurses for years to come.

                          ____________________