[Congressional Record Volume 155, Number 56 (Thursday, April 2, 2009)]
[Senate]
[Pages S4320-S4331]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Casey, Mr. Kohl, and Mr. Udall, 
        of New Mexico):
  S. 790. A bill to improve access to health care services in rural, 
frontier, and urban underserved areas in the United States by 
addressing the supply of health professionals and the distribution of 
health professionals to areas of need; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I rise today with Senators Robert Casey, 
Herb Kohl, and Tom Udall to introduce the Health Access and Health 
Professions Supply Act of 2009.
  Health care reform is a national priority--far too many Americans do 
not have access to meaningful, affordable health insurance. But even if 
every person in the U.S. had health insurance, we do not have a 
cohesive or coordinated strategy to address health workforce 
emergencies and shortages, and problems with reliable access to 
quality, affordable care. Over 20 percent of Americans are living in 
health professions shortage areas without access to adequate medical, 
dental, and mental and behavioral health services. This workforce 
deficiency will worsen as the population ages and grows by an estimated 
25 million individuals per decade and, could be severely exacerbated by 
epidemics and disasters. It is estimated that without intervention, the 
United States will experience shortages of as many as 200,000 
physicians and one million nurses by 2020. It takes many years to 
create a pipeline of health professionals. I am introducing the Health 
Access and Health Professions Supply Act of 2009 to coordinate our 
health workforce strategy, to build and maintain this pipeline, so that 
health and safety of every American is protected. The legislation is 
based on the most recent recommendations developed by Council on 
Graduate Medical Education and other health workforce experts.
  This legislation addresses these issues in an unprecedented and 
comprehensive manner. It creates a Permanent National Health Workforce 
Commission to assure that the Federal investment in the education of 
health professionals is a public good that address the needs of the 
American people. The Commission is tasked to design, revise, implement 
and evaluate programs, grants, and regulations related to the nation's 
health workforce.
  The Health Access and Health Professions Supply Act of 2009 expands 
the Medicare medical home demonstration project. This pilot program 
would include 1,000 medical home primary care providers working in 
interdisciplinary teams. These clinicians will provide the highest 
quality medical care using the best health information technology, and 
personalized, coordinated, and accessible care.
  But new models are not enough. We have allowed our primary care 
educational infrastructure to crumble. Without intervention, the 
decline will likely continue, and access to care in underserved areas 
will rapidly deteriorate. Family physicians represent 58 percent of the 
rural physician workforce, 70 percent of non-federal physicians in 
whole-county health professional shortage areas, and 78 percent of 
primary care physician full-time equivalents in the National Health 
Service Corps. Yet, the number of graduates from medical school in the 
U.S. who choose to practice family medicine has plummeted 50 percent in 
less than 10 years. Currently, less than 5 percent of graduates from 
medical school specialize in primary care. This is despite the fact 
that one of the most significant measures of the effectiveness and 
efficiency of a healthcare system is the degree to which the population 
has access to meaningful and coordinated primary care.
  Experts tell us that the dearth of primary care providers may be 
attributed to many factors including low reimbursement levels and a 
lack of federal incentives to teaching institutions to promote primary 
care. My legislation would allow the National Health Workforce 
Commission to analyze these issues and recommend solutions including 
changes in Federal reimbursement systems. For example, this bill calls 
for improved transparency and accountability for Federal dollars spent 
for medical education through direct Graduate Medical Education, GME, 
and Indirect Medical Education, IME, and money paid in Disproportionate 
Share, DSH, support for safety net services provided under the Medicare 
and Medicaid programs.
  This legislation also substantially increases funding for the 
National Health Service Corps. This will help provide healthcare access 
to the areas of our country that are in most desperate need. Also, 
included are expanded loan forgiveness and grant programs to develop 
new training programs in rural and other underserved communities to 
help us train health professionals in areas where they are needed.
  The Health Access and Health Professions Supply Act of 2009 
establishes a U.S. Public Health Sciences Track to train physicians, 
dentists, nurses, physician assistants, mental and behavior health 
specialists, pharmacists, and public health professionals emphasizing 
team-based service, public health, epidemiology, and emergency 
preparedness and response in affiliated institutions. Students in this 
program are accepted as Commission Corps officers in the U.S. Public 
Health Service and will receive tuition remission and a stipend with a 
two year service commitment for each year of school covered. This group 
will form an elite cadre of healthcare professionals that can be 
deployed when epidemics, natural or other disasters strike.
  I am introducing the Health Access and Health Professions Supply Act 
of 2009 with the understanding that our health workforce shortfall 
cannot be solved using a piecemeal approach. We must address health 
workforce issues in health care reform to guarantee access to quality 
care for all Americans but we must also ensure that taxpayer dollars 
used to support health professions education are spent wisely.
  This legislation has received widespread support and is endorsement 
by the: National Association of Community Health Centers, National 
Rural Health Association, American Medical Students Association, Trust 
for America's Health, American Psychological Association, American 
Association of Colleges of Pharmacy, American Academy of Physician 
Assistants, Commissioned Officers Association of the U.S. Public Health 
Service, National Rural Recruitment and Retention Network, American 
Academy of Child and Adolescent Psychiatry, New Mexico Health 
Resources, New Mexico Medical Society, New Mexico Chapter of the 
American College of Physicians, and the Santa Fe Project Access.

[[Page S4321]]

  I urge my colleagues in the Senate to join us in support of the 
Health Access and Health Professions Supply Act of 2009.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                 S. 790

       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 ``Health 
     Access and Health Professions Supply Act of 2009'' or 
     ``HAHPSA 2009''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

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

             TITLE I--AMENDMENTS TO THE SOCIAL SECURITY ACT

Sec. 101. Permanent National Health Workforce Commission.
Sec. 102. State health workforce centers program.
Sec. 103. Medicare medical home service and training pilot program.
Sec. 104. Improvements to payments for graduate medical education under 
              medicare.
Sec. 105. Distribution of resident trainees in an emergency.
Sec. 106. Authority to include costs of training of psychologists in 
              payments to hospitals for approved educational activities 
              under Medicare.

         TITLE II--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

Sec. 201. Expansion of National Health Service Corps programs.
Sec. 202. National health service corps scholarship program for 
              medical, dental, physician assistant, pharmacy, 
              behavioral and mental health, public health, and nursing 
              students in the United States public health sciences 
              track in affiliated schools.
Sec. 203. Federal medical facility grant program and program 
              assessments.
Sec. 204. Health professions training loan program.
Sec. 205. United States Public Health Sciences Track.
Sec. 206. Medical education debt reimbursement for physicians of the 
              Veterans Health Administration.

 TITLE III--HEALTH PROFESSIONAL TRAINING PIPELINE PARTNERSHIPS PROGRAM

Sec. 301. Grants to prepare students for careers in health care.

     SEC. 2. FINDINGS.

       (a) Findings Related to Health Care Access in Rural, 
     Frontier, and Urban Underserved Areas of the United States.--
     Congress finds the following:
       (1) The United States does not have a cohesive or 
     coordinated approach to addressing health workforce shortages 
     and problems with reliable access to quality, affordable 
     health care.
       (2) There are 50,000,000 citizens of the United States 
     living in areas that are designated under section 
     332(a)(1)(A) of the Public Health Service Act as health 
     professional shortage areas.
       (3) The population of the United States will grow by 
     25,000,000 each decade.
       (4) The number of individuals over 65 years of age in the 
     United States will double between 2000 and 2030, with such 
     individuals accounting for 20 percent of the total population 
     of the United States in 2030.
       (5) Individuals over 65 years of age have twice as many 
     doctor visits as those individuals under 65 years of age, 
     resulting in an increase in the demand for physicians, 
     physician assistants, pharmacists behavioral and mental 
     health professionals, nurses, and dentists.
       (6) The rates of chronic diseases (such as diabetes) are 
     increasing in the population of the United States.
       (7) There are 47,000,000 citizens of the United States who 
     do not have health insurance, and over 130,000,000 
     individuals within the United States who do not have dental 
     insurance. Those individuals who are uninsured have limited 
     access to health care.
       (8) Academic health centers, Federal medical facilities, 
     and teaching hospitals provide a substantial percentage of 
     safety net services in the United States to uninsured and 
     underinsured populations and to those individuals who have 1 
     or more chronic diseases. Such centers, facilities, and 
     teaching hospitals provide those safety net services while 
     concurrently providing for the training of health 
     professionals.
       (9) The pipeline for the education of health 
     professionals--
       (A) begins and often ends in urban areas;
       (B) does not reliably include Federal support for 
     nonphysician training;
       (C) does not incorporate modern training venues and 
     techniques, including community-based ambulatory sites; and
       (D) discourages interdisciplinary, team, and care 
     coordination models as a result of restrictive regulations.
       (10) Health reform must include measures to transform the 
     health delivery system to assure access, quality, and 
     efficiency by utilizing contemporary models and venues of 
     care.
       (11) Reform of the health delivery system will require 
     modernization of the training of health professionals to 
     ensure that health professionals--
       (A) practice in integrated teams in a variety of delivery 
     venues (including inpatient and ambulatory settings and long-
     term care facilities) to utilize decision support and health 
     information systems;
       (B) deliver patient-centered care;
       (C) practice evidence-based health care;
       (D) learn performance-based compensation systems, 
     comparative effectiveness, and costs of care across the 
     spectrum; and
       (E) deliver culturally appropriate, personalized care.
       (b) Findings Related to Access to Oral Health.--Congress 
     finds the following:
       (1) Dental care is the number 1 unmet health care need in 
     children, and is 1 of the top 5 unmet health care needs in 
     adults.
       (2) Over 130,000,000 citizens of the United States are 
     without dental insurance.
       (3) Over 45,000,000 citizens of the United States live in 
     areas that are designated under section 332(a)(1)(A) of the 
     Public Health Service Act as dental health professional 
     shortage areas.
       (4) Rural counties have less than half the number of 
     dentists per capita compared to large metropolitan areas (29 
     versus 62 for population of 100,000).
       (5) In 2006, over 9,000 dentists were needed in such dental 
     health professional shortage areas.
       (6) Between 27 and 29 percent of children and adults in the 
     United States have untreated cavities.
       (7) The number of dental school graduates in the United 
     States decreased by 20 percent between 1982 and 2003 and the 
     average age of practicing dentists in the United States is 
     49.
       (8) There were over 400 dental faculty vacancies in the 
     school year beginning in 2006.
       (9) In 2007, the average debt of a dental student at 
     graduation was $172,627.
       (c) Findings Related to Physician Shortages, Education, and 
     Distribution.--Congress finds the following:
       (1) By 2020, physician shortages are forecasted to be in 
     the range of 55,000 to 200,000.
       (2) Although 21 percent of the population of the United 
     States lives in rural areas, only 10 percent of physicians 
     work in rural areas and, for every 1 physician who goes into 
     practice in regions with a low supply of physicians, 4 
     physicians go into practice in regions with a high supply of 
     physicians.
       (3) According to a 2004 report by Green et al. for the 
     Robert Graham Center of the American Academy of Family 
     Physicians, the number of applicants from rural areas 
     accepted to medical school has decreased by 40 percent in the 
     last 20 years while the number of such applications has 
     remained the same.
       (4) In order to respond to forecasted shortages, experts 
     have recommended an increase between 15 and 30 percent in 
     class size at medical schools over the next 10 years.
       (5) There are 55,000,000 citizens of the United States who 
     lack adequate access to primary health care because of 
     shortages of primary care providers in their communities.
       (6) The number of graduates from medical school in the 
     United States who choose to practice family medicine has 
     plummeted 50 percent in less than 10 years. Without 
     congressional intervention, such decline will likely 
     continue, and access to care in underserved areas will 
     rapidly deteriorate. Family physicians represent 58 percent 
     of the rural physician workforce, 70 percent of non-Federal 
     physicians in whole-county health professional shortage 
     areas, and 78 percent of primary care physician full-time 
     equivalents in the National Health Service Corps.
       (7) Current trends indicate that fewer resident trainees 
     from pediatric and internal medicine residencies pursue 
     generalist practice at graduation.
       (8) Funding for medical education which is provided through 
     direct Graduate Medical Education (GME) and Indirect Medical 
     Education (IME) under the Medicare program is not transparent 
     or accountable, nor is it aligned to the types of health 
     professionals most needed or to the areas in which health 
     professionals are most needed.
       (9) Physician supply varies 200 percent across regions and 
     there is no relationship between regional physician supply 
     and health needs.
       (10) The Council on Graduate Medical Education's 18th 
     Report (issued in 2007), entitled ``New Paradigms for 
     Physician Training for Improving Access to Health Care'', and 
     19th Report (issued in 2007), entitled ``Enhancing 
     Flexibility in Graduate Medical Education'', each call for 
     changes to address the healthcare needs of the United States 
     by removing barriers to expanding and more appropriately 
     training the physician workforce.
       (d) Findings Related to Nursing Shortages, Education, and 
     Distribution.--Congress finds the following:
       (1) By 2020, nursing shortages are forecast to be in the 
     range of 300,000 to 1,000,000 and the Bureau of Labor 
     Statistics of the Department of Labor estimates that more 
     than 1,200,000 new and replacement registered nurses will be 
     needed by 2014.
       (2) Nurse vacancy rates are currently 8 percent or greater 
     in hospitals and community health centers receiving 
     assistance under

[[Page S4322]]

     section 330 of the Public Health Service Act, and for nursing 
     faculty positions.
       (3) Surveys indicate that 40 percent of nurses in hospitals 
     are dissatisfied with their work and, of nurses who graduate 
     and go into nursing, 50 percent leave their first employer 
     within 2 years.
       (4) Nursing baccalaureate and graduate programs rejected 
     more than 40,000 qualified nursing school applicants in 2006, 
     with faculty shortages identified by such programs as a major 
     reason for turning away qualified applicants.
       (5) More than 70 percent of nursing schools cited faculty 
     shortages as the primary reason for not accepting all 
     qualified applicants into entry-level nursing programs.
       (6) The nursing faculty workforce is aging and retiring 
     and, by 2019, approximately 75 percent of the nursing faculty 
     workforce is expected to retire.
       (7) The average age of nurses in the United States is 49 
     and the average age of an associate professor nurse faculty 
     member in the United States is 56.
       (8) Geriatric patients receiving care from nurses trained 
     in geriatrics are less frequently readmitted to hospitals or 
     transferred from skilled nursing facilities and nursing 
     facilities to hospitals.
       (e) Findings Related to Public Health Workforce 
     Shortages.--Congress finds the following:
       (1) The United States has an estimated 50,000 fewer public 
     health workers than it did 20 years ago while the population 
     has grown by approximately 22 percent.
       (2) Government public health departments are facing 
     significant workforce shortages that could be exacerbated 
     through retirements.
       (3) Twenty percent of the average State health agency's 
     workforce will be eligible to retire within 3 years, and by 
     2012, over 50 percent of some State health agency workforces 
     will be eligible to retire.
       (4) Approximately 20 percent of local health department 
     employees will be eligible for retirement by 2010.
       (5) The average age of new hires in State health agencies 
     is 40.
       (6) 4 out of 5 current public health workers have not had 
     formal training for their specific job functions.
       (f) Findings Related to Physician Assistant Shortages.--
     Congress finds the following:
       (1) The purpose of the physician assistant profession is to 
     extend the ability of physicians to provide primary care 
     services, particularly in rural and other medically 
     underserved communities.
       (2) Physician assistants always practice medicine as a team 
     with their supervising physicians, however, supervising 
     physicians need not be physically present when physician 
     assistants provide medical care.
       (3) Physician assistants are legally regulated in all 
     States, the District of Columbia, and Guam. All States, the 
     District of Columbia, and Guam authorize physicians to 
     delegate prescriptive authority to physician assistants.
       (4) In 2007, physician assistants made approximately 
     245,000,000 patient visits and prescribed or recommended 
     approximately 303,000,000 medications.
       (5) The National Association of Community Health Centers, 
     the George Washington University, and the Robert Graham 
     Center for Policy Studies in Family Medicine and Primary Care 
     found that while the number of patients who seek care at 
     community health centers has increased, the number of primary 
     care providers, including physician assistants, has not. The 
     report estimates a need for 15,500 primary health care 
     providers to provide care at community health centers.
       (g) Findings Related to Mental Health Professional 
     Shortages.--Congress finds the following:
       (1) The National Institute of Mental Health estimates that 
     26.2 percent of citizens of the United States ages 18 and 
     older suffer from a diagnosable mental disorder. 
     Approximately 20 percent of children in the United States 
     have diagnosable mental disorders with at least mild 
     functional impairment.
       (2) The Health Resources and Services Administration 
     reports that there are 3,059 mental health professional 
     shortage areas within the United States with 77,000,000 
     people living in those areas. More than 5,000 additional 
     mental health professionals are needed to meet demand.
       (3) According to the Department of Health and Human 
     Services, minority representation is lacking in the mental 
     health workforce. Although 12 percent of the population of 
     the United States is African-American, only 2 percent of 
     psychologists, 2 percent of psychiatrists, and 4 percent of 
     social workers are African-American. Moreover, there are only 
     29 mental health professionals who are Hispanic for every 
     100,000 individuals who are Hispanic in the United States, 
     compared with 173 non-Hispanic White providers for every 
     100,000 individuals who are non-Hispanic White in the United 
     States.
       (h) Findings Related to Health Professional Shortage 
     Areas.--
       (1) In 2006, the National Health Service Corps had a total 
     of 4,200 vacant positions in health professional shortage 
     areas, but only 1,200 of those positions were funded. For 
     each National Health Service Corps award, there are 7 
     applicants.
       (2) Community health centers receiving assistance under 
     section 330 of the Public Health Service Act have expanded to 
     serve 16,000,000 individuals in over 1,000 sites. Such 
     community health centers have high vacancy rates for family 
     physicians (13 percent), obstetricians and gynecologists (21 
     percent), dentists, nurses, and other health professionals.
       (3) The Institute of Medicine of the National Academies has 
     recommended that medical education and public health issues 
     be more closely aligned, especially in relation to 
     preparedness for natural disasters, pandemic, bioterrorism, 
     and other threats to public health.
       (4) The education of health professionals must be more 
     closely aligned with health care needs in the United States, 
     with special attention to underserved populations and areas, 
     health disparities, the aging population, and individuals 
     with 1 or more chronic diseases.
       (5) There is some duplication, and little coordination, 
     between the Council on Graduate Medical Education (related to 
     the physician workforce), the National Advisory Committee on 
     Nursing Programs (related to the nursing workforce), the 
     Advisory Committee on Training in Primary Care Medicine and 
     Dentistry, and other advisory committees and councils.
       (6) The Association of Academic Health Centers calls for 
     making the health workforce of the United States a priority 
     domestic policy issue and creating a national health 
     workforce planning body that engages Federal, State, public, 
     and private stakeholders.

             TITLE I--AMENDMENTS TO THE SOCIAL SECURITY ACT

     SEC. 101. PERMANENT NATIONAL HEALTH WORKFORCE COMMISSION.

       (a) Establishment.--There is hereby established the 
     Permanent National Health Workforce Commission (in this 
     section referred to as the ``Commission'').
       (b) Duties.--
       (1) Review of federal policies and annual reports.--
       (A) Review.--The Commission shall review Federal policies 
     with respect to the training, financing, and distribution of 
     the health professional workforce, particularly with respect 
     to such workforce in rural, frontier, and urban underserved 
     areas, including the specific topics described in paragraph 
     (2). Such review shall include a comprehensive analysis and 
     reporting of--
       (i) the most recent COHPPERDDUST Annual Report;
       (ii) the number of medical students and residents, 
     physician assistant students, pharmacy students and 
     residents, behavioral and mental health students and 
     residents, dental students and residents, nursing students 
     and advance practice nursing trainees, and other health 
     professionals in need of training, the rates of payment for 
     such training; and the methodologies for funding such 
     training;
       (iii) how to align payments for direct graduate medical 
     education costs under section 1886(h) of the Social Security 
     Act (42 U.S.C. 1395ww(h)) and payments for the indirect costs 
     of medical education under section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) with other 
     Federal and State subsidies and payments for health 
     professions education with desired outcomes for the health 
     professional workforce;
       (iv) whether Federal medical facilities should be permitted 
     to train health professionals with support paid directly by 
     the entity sponsoring the health professional;
       (v) whether the establishment of transparent, accountable 
     Federal payment policies for training health professionals 
     would ensure that the types of health professionals trained 
     and the distribution of such health professionals would meet 
     the health care needs of the population of the United States;
       (vi) the feasibility of establishing a National Health 
     Professions Education Trust Fund to ensure an open and fair 
     system of Federal, State, and private support for providing 
     education for health professionals; and
       (vii) any other issues related to such Federal policies as 
     the Commission determines appropriate.
       (B) COHPPERDDUST annual reports.--Not later than each of 
     January 1 of each year (beginning with 2012) the Commission 
     shall submit to the Secretary and to Congress a report 
     containing--
       (i) the results of the review conducted under subparagraph 
     (A); and
       (ii) recommendations--

       (I) with respect to the Health Professions Pipeline, 
     Education, Research, Diversity & Distribution to Underserved 
     Areas Utilizing Service/Training Models; and
       (II) for such legislation or administrative action, 
     including regulations, as the Commission determines 
     appropriate.

       (2) Specific topics described.--
       (A) Payments for health professions education.--
     Specifically, the Commission shall review, with respect to 
     the training, financing, and distribution of the health 
     professional workforce, the following:
       (i) The regular update, revision, and standardization of 
     hospital-specific and sponsoring institution-specific base-
     period per resident amounts and cost reporting periods for 
     payments for direct graduate medical education costs under 
     section 1886(h) of the Social Security Act (42 U.S.C. 
     1395ww(h)) and payments for the indirect costs of medical 
     education under section 1886(d)(5)(B) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)).
       (ii) The feasibility of the Secretary, subject to review by 
     the Commission, granting a waiver under the Medicare program, 
     such as

[[Page S4323]]

     the waiver granted to the Utah Medical Education Commission, 
     which would allow States flexibility to utilize funding under 
     titles XVIII, XIX, and XXI of the Social Security Act for 
     direct graduate medical education and indirect graduate 
     medical education to support coordinated and comprehensive 
     health workforce training innovations.
       (iii) Replacement of the current methodology for making 
     payments for such direct graduate medical education costs and 
     such indirect costs of medical education with a workforce 
     adjustment payment, based on a Sustainable Growth Rate 
     formula or a prospective payment system, under which--

       (I) payments would be made directly to the sponsoring 
     institution where such education is provided; and
       (II) payments would be separated to reflect the costs to 
     the professional and facility components of such education.

       (iv) The establishment of standards for the financing of 
     education for health professionals who are not physicians.
       (v) The expansion of the definition, for purposes of making 
     payments for health professions education (including such 
     direct graduate medical education costs and such indirect 
     costs of medical education), of the term ``sponsoring 
     institution'', which traditionally has been a teaching 
     hospital or medical school, to include nonteaching hospital-
     based entities (such as managed care organizations and public 
     and private healthcare consortia) that are capable of 
     assembling all of the resources necessary for effectively 
     providing the training and education required to address 
     healthcare access, quality, and costs and to meet workforce 
     needs.
       (vi) The provision of health professions education by 
     nonteaching hospital-based entities (including rural health 
     clinics (as defined in subsection (aa)(2) of section 1861 of 
     the Social Security Act (42 U.S.C. 1395x)), community health 
     centers (as defined in section 330 of the Public Health 
     Service Act (42 U.S.C. 254b)), and Federally qualified health 
     centers (as defined in subsection (aa)(4) of such section 
     1861) that are not sponsoring institutions (as defined under 
     clause (v)) as affiliates of the sponsoring institution for 
     purposes of providing more limited, but highly valuable 
     clinical training.
       (vii) The establishment of incentives to promote 
     interdisciplinary, team-based, and care coordination-based 
     education of health professionals, including incentives to 
     encourage the development of health information technology 
     (such as a repository of consumer health status information 
     in computer processable form) which can be used for 
     diagnosis, management, and treatment and includes price and 
     cost information.
       (viii) Adjustment to the Medicare caps on graduate medical 
     education positions to increase the number of primary care 
     residents, general dentistry residents, geriatric fellowship 
     trainees, and other health professionals trained in Federal 
     medical facilities.
       (ix) The development of pay-for-performance methodologies 
     for payments for health professions education (including such 
     direct graduate medical education costs, payments for such 
     indirect costs of medical education, and disproportionate 
     share payments under section 1886(d)(5)(F) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(F))) to--

       (I) increase payments to sponsoring institutions and the 
     affiliates of such institutions that achieve desired 
     outcomes; and
       (II) reduce payments to such institutions and such 
     affiliates that do not perform.

       (x) The correlation between Federal policies with respect 
     to the training, financing, and distribution of the health 
     professional workforce and specific evidence-based, 
     measurable, and comparative outcomes across sponsoring 
     institutions and the affiliates of such institutions.
       (xi) Disproportionate share payments under section 
     1886(d)(5)(F) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(F)) made to service and training institutions 
     that provide safety net access, community-based outreach 
     programs, measurable and transparent community benefit, and 
     planned financial assistance to low-income patients, Medicare 
     beneficiaries, and underinsured (including uninsured) 
     individuals in rural, frontier, and urban underserved areas.
       (xii) The establishment of a workforce adjustment payment 
     under the Medicare program under title XVIII of the Social 
     Security Act, the Medicaid program under title XIX of such 
     Act, the State Children's Health Insurance Program under 
     title XXI of such Act, and other publicly funded health 
     insurance programs to support training programs for health 
     professionals in Federal medical facilities, under which such 
     workforce adjustment payment would be made directly to the 
     sponsoring institution. Such payment would, as the Secretary 
     determines appropriate, in consultation with the Commission, 
     replace or supplement the provisions under clause (iii).
       (B) Data collection and review.--Specifically, the 
     Commission shall review, with respect to the adequacy, 
     supply, and distribution of undergraduate and graduate 
     education programs for health professionals, the following:
       (i) Available data on the adequacy, supply, and 
     distribution of such education programs for physicians, 
     physician assistants, nurses, dentists, psychologists, 
     pharmacists, behavioral and mental health professionals (as 
     defined in section 331(a)(3)(E)(i) of the Public Health 
     Service Act (42 U.S.C. 254d(a)(3)(E)(i)), public health 
     professionals, and other health professionals, including data 
     collected under the State Health Workforce Centers Program 
     established under section 102.
       (ii) Processes for improving the collection of data on 
     health professionals, including the collection of more 
     consistent, independent, and comprehensive data from entities 
     (such as State licensure boards) to inform health professions 
     workforce issues. In conducting such review, the Commission 
     shall determine the costs of implementing such data 
     collection.
       (3) Conduct of hearings.--
       (A) In general.--The Commission shall conduct hearings on 
     health professions education to assess performance, identify 
     barriers, speed approval of innovative programs, improve 
     flexibility, and reduce bureaucratic obstacles balancing 
     hospital training while emphasizing sustained affiliation 
     agreements with community-based, interdisciplinary, team, and 
     care management methodologies and education designed to 
     improve quality and efficiency of patient care across the 
     care delivery system.
       (B) Testimony.--In conducting hearings under subparagraph 
     (A), the Commission shall solicit testimony from the 
     Accreditation Council for Graduate Medical Education, 
     Residency Review Committees, and other appropriate 
     organizations that accredit education programs for health 
     professionals.
       (C) Information from federal agencies.--
       (i) In general.--The Commission may secure directly from a 
     Federal agency such information as the Commission considers 
     necessary to carry out this section.
       (ii) Provision of information.--The head of the agency 
     shall provide the information to the Commission at the 
     request of the Chairperson of the Commission.
       (4) Reducing health professional isolation and building 
     community health professional training infrastructure.--
       (A) Identification of programs.--The Commission shall 
     identify programs to reduce health professional isolation and 
     build community health professional training infrastructure 
     in rural, frontier, and urban underserved areas through 
     continuing education (including continuing education 
     utilizing information technology, such as telehealth and 
     health information technology), mentoring, and precepting 
     activities.
       (B) Analysis.--The Commission shall examine--
       (i) whether the establishment of regional or statewide 
     Health Advice Lines would reduce after-hours calls 
     responsibilities for overworked health professionals in 
     remote sites with few health professionals available to 
     fulfill such responsibilities; and
       (ii) what support should be given to health professionals 
     fulfilling such responsibilities--

       (I) in hospitals and emergency departments in areas 
     designated under section 332 of the Public Health Service Act 
     as health professional shortage areas;
       (II) under practice relief programs that allow health 
     professionals practicing in such areas to have their practice 
     and calls covered when they are ill, pursuing continuing 
     education, or taking a vacation;
       (III) with respect to field faculty development to become 
     supervisors, mentors, and preceptors for health professional 
     students and trainees;

       (iii) support structures (such as Area Health Education 
     Centers) for health professionals; and
       (iv) whether the establishment of Rural Health Education 
     Offices, based on the model of agricultural extension 
     offices, would--

       (I) help build community health professional service and 
     training capacity; and
       (II) spur local economic development.

       (5) Development of guiding principles and accountability 
     standards.--The Commission shall develop guiding principles 
     and accountability standards for Federal, State, and private 
     sector education of health professionals. Such guidelines 
     shall be crafted to assure that the Federal investment in the 
     education of health professionals is a public good, 
     regardless of whether a portion of such education is funded 
     by other sources.
       (6) Identification of state and regional health professions 
     education commissions.--The Commission shall identify State 
     and regional Health Professions Education Centers. The 
     Commission shall enter into agreements with such Centers 
     under which the Centers shall provide data and reports to the 
     Commission to provide a balanced and adequate assessment of 
     the entire Nation's healthcare workforce.
       (c) Secretarial Responsibilities.--Not later than 18 months 
     after the date of enactment of this Act, the Secretary shall, 
     in consultation with the Commission, and through negotiated 
     rulemaking, promulgate regulations to address the matters 
     reviewed under clauses (i) through (vii) of subsection 
     (b)(1)(A), as the Secretary determines appropriate to address 
     access and health professional shortages and needs identified 
     by the Commission with respect to titles XVIII, XIX, and XXI 
     of the Social Security Act.
       (d) Membership.--
       (1) Number of appointment.--The Commission shall be 
     composed of 20 members appointed by the Comptroller General 
     of the United States.
       (2) Qualifications.--The membership of the Commission shall 
     include representatives of--

[[Page S4324]]

       (A) dentists and dental hygienists who practice in urban 
     underserved and rural areas;
       (B) primary care providers who practice in urban 
     underserved and rural areas;
       (C) nurses and physician assistants who practice in urban 
     underserved and rural areas;
       (D) psychologists and other behavioral and mental health 
     professionals (as defined in section 331(a)(3)(E)(i) of the 
     Public Health Service Act (42 U.S.C. 254d(a)(3)(E)(i)) who 
     practice in urban underserved and rural areas;
       (E) public health professionals;
       (F) clinical pharmacists who practice in a Federal market 
     or are sole-community providers;
       (G) national and specialty physician and nursing 
     organizations;
       (H) schools of medicine, osteopathy, and nursing, 
     educational programs for public health professionals, 
     behavioral and mental health professionals (as so defined), 
     and physician assistants, public and private teaching 
     hospitals, and ambulatory health facilities, including 
     Federal medical facilities;
       (I) health insurers;
       (J) business;
       (K) labor; and
       (L) any other health professional organization or practice 
     site the Comptroller General determines appropriate.
       (e) Staff.--
       (1) In general.--The Comptroller General of the United 
     States shall provide for the appointment of an executive 
     director, deputy director, and such other additional 
     personnel as are necessary to enable the Commission to 
     perform the duties of the Commission.
       (2) Compensation.--
       (A) In general.--Except as provided in subparagraph (B), 
     the Comptroller General of the United States may fix the 
     compensation of the executive director, deputy director, and 
     other personnel without regard to the provisions of chapter 
     51 and subchapter III of chapter 53 of title 5, United States 
     Code, relating to classification of positions and General 
     Schedule pay rates.
       (B) Maximum rate of pay.--The rate of pay for the executive 
     director, deputy director, and other personnel shall not 
     exceed the rate payable for level V of the Executive Schedule 
     under section 5316 of title 5, United States Code.
       (3) Detail of federal government employees.--
       (A) In general.--An employee of the Federal Government may 
     be detailed to the Commission without reimbursement.
       (B) Civil service status.--The detail of the employee shall 
     be without interruption or loss of civil service status or 
     privilege.
       (4) Procurement of temporary and intermittent services.--
     The Commission may procure temporary and intermittent 
     services in accordance with section 3109(b) of title 5, 
     United States Code, at rates for individuals that do not 
     exceed the daily equivalent of the annual rate of basic pay 
     prescribed for level V of the Executive Schedule under 
     section 5316 of that title.
       (f) Powers.--
       (1) Hearings.--The Commission may hold such hearings, meet 
     and act at such times and places, take such testimony, and 
     receive such evidence as the Commission considers advisable 
     to carry out this section.
       (2) Information from federal agencies.--
       (A) In general.--The Commission may secure directly from a 
     Federal agency such information as the Commission considers 
     necessary to carry out this section.
       (B) Provision of information.--On request of the 
     Chairperson of the Commission, the head of the agency shall 
     provide the information to the Commission.
       (3) Postal services.--The Commission may use the United 
     States mails in the same manner and under the same conditions 
     as other agencies of the Federal Government.
       (4) Gifts.--The Commission may accept, use, and dispose of 
     gifts or donations of services or property.
       (g) Status as Permanent Commission.--Section 14 of the 
     Federal Advisory Committee Act (5 U.S.C. App.) shall not 
     apply to the Commission.
       (h) Definitions.--In this section:
       (1) COHPPERDDUST annual report.--The term ``COHPPERDDUST 
     Annual Report'' means the annual report submitted by the 
     Commission under subsection (b)(1)(B).
       (2) Federal medical facility.--The term ``Federal medical 
     facility'' means a facility for the delivery of health 
     services, and includes--
       (A) a Federally qualified health center (as defined in 
     section 1861(aa)(4) of the Social Security Act (42 U.S.C. 
     1395x(aa)(4)), a public health center, an outpatient medical 
     facility, or a community mental health center;
       (B) a hospital, State mental hospital, facility for long-
     term care, or rehabilitation facility;
       (C) a migrant health center or an Indian Health Service 
     facility;
       (D) a facility for the delivery of health services to 
     inmates in a penal or correctional institution (under section 
     323 of such Act (42 U.S.C. 250)) or a State correctional 
     institution;
       (E) a Public Health Service medical facility (used in 
     connection with the delivery of health services under section 
     320, 321, 322, 324, 325, or 326 of such Act (42 U.S.C. 247e, 
     248, 249, 251, 252, or 253));
       (F) a nurse-managed health center; or
       (G) any other Federal medical facility.
       (3) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

     SEC. 102. STATE HEALTH WORKFORCE CENTERS PROGRAM.

       (a) Establishment.--The Secretary shall establish a 
     demonstration program (in this section referred to as the 
     ``program'') under which the Secretary makes grants to 
     participating States for the operation of State Health 
     Workforce Centers to carry out the activities described in 
     subsection (c).
       (b) Participating States.--A State seeking to participate 
     in the program shall submit an application to the Secretary 
     containing such information and at such time as the Secretary 
     may specify. The Secretary may only consider under the 
     preceding sentence 1 application submitted by each State 
     which has been certified by the Governor or the chief 
     executive officer of the State.
       (c) Use of Funds.--Grants awarded under subsection (a) may 
     be used to support activities designed to improve the 
     training, deployment, and retention of critical health 
     professionals in underserved areas and for underserved 
     populations, including the following:
       (1) Conducting assessments of key health professional 
     capacity and needs. Such assessments shall be conducted in a 
     coordinated manner that provides for the nationwide 
     collection of health professional data.
       (2) Convening State health professional policymakers to 
     review education, education financing, regulations, and 
     taxation and compensation policies which affect the training, 
     deployment, and retention of health professionals. A 
     participating State may, taking into consideration the 
     results of such reviews, develop short-term and long-term 
     recommendations for improving the supply, deployment, and 
     retention of critical health professionals in underserved 
     areas and for underserved populations.
       (d) Funding.--
       (1) Authorization of appropriations.--There are authorized 
     to be appropriated $13,750,000 to carry out this section.
       (2) Matching requirement.--The Secretary may require a 
     State, in order to be eligible to receive a grant under this 
     section, to agree that, with respect to the costs incurred by 
     the State in carrying out the activities for which the grant 
     was awarded, the State will make available (directly or 
     through donations from public or private entities) non-
     Federal contributions in an amount equal to a percent of 
     Federal funds provided under the grant (as determined 
     appropriate by the Secretary).
       (e) Definitions.--In this section:
       (1) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (2) State.--The term ``State'' means--
       (A) a State;
       (B) the District of Columbia;
       (C) the Commonwealth of Puerto Rico; and
       (D) any other territory or possession of the United States.

     SEC. 103. MEDICARE MEDICAL HOME SERVICE AND TRAINING PILOT 
                   PROGRAM.

       (a) Expansion of Medicare Medical Home Demonstration 
     Project.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     expand the Medicare medical home demonstration project under 
     section 204 of Division B of the Tax Relief and Health Care 
     Act of 2006 (Public Law 109-432; 120 Stat. 2987) by adding a 
     Medicare medical home service and training pilot program (in 
     this section referred to as the ``pilot program'') to 
     redesign the methodologies for payments to primary care 
     providers for coordinating the care of applicable Medicare 
     beneficiaries. Such pilot program shall be in addition to, 
     and run concurrently with, the Medicare medical home 
     demonstration program. Except for any modifications under 
     this section, the Secretary shall carry out the pilot program 
     under similar terms and conditions as the Medicare medical 
     home demonstration program.
       (2) Applicable medicare beneficiaries defined.--In this 
     section, the term ``applicable Medicare beneficiary'' means 
     an individual who--
       (A) is entitled to, or enrolled for, benefits under part A 
     of title XVIII of the Social Security Act, or is enrolled 
     under part B of such title;
       (B) has 1 or more chronic illnesses (such as diabetes, 
     hypertension, chronic obstructive pulmonary disease, asthma, 
     congestive heart failure, end stage liver disease, and end 
     stage renal disease); and
       (C) is in the top 2 quartiles of cost under the Medicare 
     program under such title (as determined based on Medicare 
     claims data for the most recent 2 years for which data is 
     available).
       (b) Details.--
       (1) Duration; scope.--The pilot program shall operate 
     during the period beginning on January 1, 2011 and ending on 
     December 31, 2014 and shall include not more than 1,000 
     medical home primary care providers.
       (2) Implementation.--
       (A) In general.--The Secretary may implement the pilot 
     program--
       (i) under title XVIII of the Social Security Act; or
       (ii) subject to subparagraph (B), under a combination of 
     such title and other public or private programs or 
     organizations.
       (B) Special rule.--In the case where the Secretary 
     implements the pilot program under a combination of title 
     XVIII of the Social Security Act and other public or private 
     programs or organizations, the Secretary shall establish 
     procedures to ensure that any funding made available under 
     such title for

[[Page S4325]]

     the pilot program is only used to furnish items and services 
     to Medicare beneficiaries.
       (3) Participation of primary care providers.--
       (A) In general.--In no case shall participation in the 
     pilot program be limited to primary care providers in those 
     States participating in the Medicare medical home 
     demonstration project under section 204 of Division B of the 
     Tax Relief and Health Care Act of 2006 (Public Law 109-432; 
     120 Stat. 2987). Any primary care provider in the United 
     States that meets the requirements and definitions under this 
     section and, if applicable, such section 204, shall be 
     eligible to participate in the pilot program. In selecting 
     primary care providers to participate in the pilot program, 
     the Secretary shall give preference to sites where clinical 
     services and health professional education are provided 
     concurrently, taking into consideration priorities of the 
     Permanent National Health Workforce Commission established 
     under section 101 of the Health Access and Health Professions 
     Supply Act of 2009.
       (B) Definition of primary care providers.--In this section, 
     the term ``primary care provider'' means--
       (i) a personal physician (as defined in subsection (c)(1) 
     of section 204 of Division B of the Tax Relief and Health 
     Care Act of 2006 (Public Law 109-432; 120 Stat. 2987), except 
     that, in applying such definition under this section, the 
     requirements described in subsection (c)(2)(B) of such 
     section 204 shall specify that the staff and resources of the 
     physician may include a team of health professionals (such as 
     nurse practitioners, clinical nurse specialists, certified 
     nurse midwives, psychologists and other behavioral and mental 
     health professionals (as defined in section 331(a)(3)(E)(i) 
     of the Public Health Service Act (42 U.S.C. 
     254d(a)(3)(E)(i)), physician assistants, and other primary 
     care providers that meet requirements established by the 
     Secretary)); and
       (ii) any other primary care provider (such as a nurse 
     practitioner or a physician assistant) that is subject to 
     State licensure laws and the requirements of the Secretary.
       (C) Limitation on number of primary care providers 
     participating in the pilot program who are not personal 
     physicians.--The Secretary shall ensure that the total number 
     of independently practicing primary care providers who are 
     not personal physicians participating in the pilot program 
     reflects the percentage of such primary care providers in the 
     United States (as determined by the Secretary), not to exceed 
     10 percent of the total number of primary care providers 
     participating in the pilot program.
       (4) Services performed.--A primary care provider shall 
     perform or provide for the performance of at least the 
     services described in subsection (c)(3) of such section 204 
     under the pilot program.
       (c) Care Coordination Fee Payment Methodology.--Under the 
     pilot program, the Secretary shall provide for payment under 
     section 1848 of the Social Security Act (42 U.S.C. 1395w-4) 
     of a per member per month care coordination fee to primary 
     care providers for the care of eligible Medicare 
     beneficiaries participating in the pilot program. The 
     Secretary shall appoint a committee to make recommendations 
     about the design and implementation of a methodology for 
     payment of the per member per month care coordination fee.
       (d) Provision of Data and Technical Assistance.--The 
     Secretary shall provide--
       (1) data to primary care providers participating in the 
     pilot program; and
       (2) technical assistance to such primary care providers 
     that do not meet the criteria for the highest tier of the 
     pilot program (as defined by the Secretary).
       (e) Reports by the Secretary.--
       (1) Interim report.--Not later than January 1, 2013, the 
     Secretary shall submit to Congress an interim report on the 
     pilot program.
       (2) Final report.--Not later than January 1, 2014, the 
     Secretary shall submit to Congress a final report on the 
     pilot program. Such report shall include outcome measures 
     reported by the Secretary under the pilot program, including 
     at least the following:
       (A) The total costs to the Medicare program per eligible 
     Medicare beneficiary participating in the pilot program.
       (B) The performance of primary care providers participating 
     in the pilot program with regard to--
       (i) quality measures developed by the Secretary; and
       (ii) patient safety indicators developed by the Secretary.
       (C) The experience of eligible Medicare beneficiaries and 
     primary care providers participating in the pilot program.
       (D) An assessment of savings to the Medicare program per 
     eligible Medicare beneficiary participating in the pilot 
     program that are a result of such participation, as compared 
     to traditional Medicare fee-for-service payment 
     methodologies.
       (f) GAO Assessment and Report.--
       (1) Assessment.--The Comptroller General of the United 
     States shall, at the completion of the pilot program, provide 
     for an overall assessment of the efficacy of the pilot 
     program.
       (2) Report.--Not later than January 1, 2014, the 
     Comptroller General shall submit to Congress a report 
     containing the results of the assessment under paragraph (1).

     SEC. 104. IMPROVEMENTS TO PAYMENTS FOR GRADUATE MEDICAL 
                   EDUCATION UNDER MEDICARE.

       (a) Increasing the Medicare Caps on Graduate Medical 
     Education Positions.--
       (1) Direct graduate medical education.--Section 
     1886(h)(4)(F) of the Social Security Act (42 U.S.C. 
     1395ww(h)(4)(F)) is amended--
       (A) in clause (i), by inserting ``clause (iii) and'' after 
     ``subject to''; and
       (B) by adding at the end the following new clause:
       ``(iii) Increase in caps on graduate medical education 
     positions for states with a shortage of residents.--

       ``(I) In general.--For cost reporting periods beginning on 
     or after January 1, 2011, the Secretary shall increase the 
     otherwise applicable limit on the total number of full-time 
     equivalent residents in the field of allopathic or 
     osteopathic medicine determined under clause (i) with respect 
     to a qualifying hospital by an amount equal to 15 percent of 
     the amount of the otherwise applicable limit (determined 
     without regard to this clause). Such increase shall be 
     phased-in equally over a period of 3 cost reporting periods 
     beginning with the first cost reporting period in which the 
     increase is applied under the previous sentence to the 
     hospital.
       ``(II) Qualifying hospital.--In this clause, the term 
     `qualifying hospital' means a hospital that agrees to use the 
     increase in the number of full-time equivalent residents 
     under subclause (I) to support community-based training which 
     emphasizes underserved areas and innovative training models 
     which address community needs and reflect emerging, evolving, 
     and contemporary models of health care delivery. A qualifying 
     hospital shall give priority to providing such training and 
     training models to health professionals in specialties which 
     the Secretary, in consultation with the Permanent National 
     Health Workforce Commission established under section 101(a) 
     of the Health Access and Health Professions Supply Act of 
     2009, determines are in high-need (including family medicine, 
     general surgery, geriatrics, general internal medicine, 
     general surgery, and obstetrics and gynecology).
       ``(III) Increase in payments.--Notwithstanding any other 
     provision of law, in the case of full-time equivalent 
     residents added to a hospital's training program as a result 
     of such increase, the Secretary shall provide for an increase 
     in the amounts otherwise payable under this subsection with 
     respect to direct graduate medical education costs that would 
     otherwise apply with respect to such residents by 10 percent. 
     Such increased payments shall be made to the facility in 
     which the training is provided to such residents.''.

       (2) Indirect medical education.--Section 1886(d)(5)(B) of 
     the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is 
     amended by adding at the end the following new clause:
       ``(x) Clause (iii) of subsection (h)(4)(F) shall apply to 
     clause (v) in the same manner and for the same period as such 
     clause (iii) applies to clause (i) of such subsection.''.
       (b) Application of Medicare GME Payments to Additional 
     Training Site Venues.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this subsection referred to as the ``Secretary'') shall, 
     by regulation, provide for the use of payments for direct 
     graduate medical education costs under section 1886(h) of the 
     Social Security Act (42 U.S.C. 1395ww(h)) and payments for 
     the indirect costs of medical education under section 
     1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(B)) to support the implementation of community-
     based training and innovative training models under 
     subsections (h)(4)(F)(iii)(II) and (d)(5)(B)(x) of section 
     1886 of the Social Security Act (42 U.S.C. 1395ww).
       (2) Use of model of care delivery.--In promulgating 
     regulations under paragraph (1), the Secretary shall consider 
     the model of care delivery of the Institute of Medicine of 
     the National Academies.
       (3) Consultation.--In promulgating such regulations, the 
     Secretary shall consult with the Permanent National Health 
     Workforce Commission established under section 101(a).
       (c) Determination of Hospital-Specific Approved FTE 
     Resident Amounts.--Section 1886(h)(2) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(2)) is amended by adding at the end 
     the following new subparagraph:
       ``(G) Flexibility in determination.--
       ``(i) In general.--Notwithstanding the preceding provisions 
     of this paragraph, the approved FTE resident amount for each 
     cost reporting period beginning on or after January 1, 2011, 
     with respect to an applicable resident shall be determined 
     using a methodology established by the Secretary that allows 
     flexibility for payments to be made for costs in addition to 
     the costs of hospital-sponsored education. Such methodology 
     shall provide that nonteaching hospital-based entities (such 
     as managed care organizations and public and private 
     healthcare consortia) that are capable of assembling all of 
     the resources necessary for effectively providing graduate 
     medical education may receive payments for providing graduate 
     medical education, either as the sponsor of such graduate 
     medical education program or as an affiliate of such a 
     sponsor.
       ``(ii) Applicable resident.--In this subparagraph, the term 
     `applicable resident' means a resident--

       ``(I) in a specialty which the Secretary, in consultation 
     with the Permanent National Health Workforce Commission 
     established under section 101(a) of the Health Access and 
     Health Professions Supply Act of 2009, determines is in high-
     need;

[[Page S4326]]

       ``(II) in a health professional shortage area (as defined 
     in section 332 of the Public Health Service Act);
       ``(III) in a medically underserved community (as defined in 
     section 799B of the Public Health Service Act), or with 
     respect to a medically underserved population (as defined in 
     section 330(b)(3) of the Public Health Service Act); and
       ``(IV) in a Federal medical facility.

       ``(iii) Federal medical facility.--In this subparagraph, 
     the term `Federal medical facility' means a facility for the 
     delivery of health services, and includes--

       ``(I) a community health center (as defined in section 330 
     of the Public Health Service Act), a public health center, an 
     outpatient medical facility, or a community mental health 
     center;
       ``(II) a hospital, State mental hospital, facility for 
     long-term care, or rehabilitation facility;
       ``(III) a migrant health center or an Indian Health Service 
     facility;
       ``(IV) a facility for the delivery of health services to 
     inmates in a penal or correctional institution (under section 
     323 of such Act) or a State correctional institution;
       ``(V) a Public Health Service medical facility (used in 
     connection with the delivery of health services under section 
     320, 321, 322, 324, 325, or 326 of such Act); or
       ``(VI) any other Federal medical facility.''.

     SEC. 105. DISTRIBUTION OF RESIDENT TRAINEES IN AN EMERGENCY.

       (a) Exclusion From 3-Year Rolling Average.--Notwithstanding 
     any other provision of law, in the case of a host hospital 
     participating in an emergency Medicare GME affiliation 
     agreement on or after the date of enactment of this Act and 
     training residents in excess of its cap, consistent with the 
     rolling average provisions applicable for closed programs as 
     specified in section 413.79(d)(6) of title 42, Code of 
     Federal Regulations, the Secretary of Health and Human 
     Services shall exclude from the 3-year rolling average FTE 
     residents associated with displaced residents during the 
     period in which such agreement is in effect.
       (b) Assessment and Revision of GME Policies.--
       (1) Review.--The Secretary of Health and Human Services 
     shall review policies with respect to payments for direct 
     graduate medical education costs under section 1886(h) of the 
     Social Security Act (42 U.S.C. 1395ww(h)) and payments for 
     the indirect costs of medical education under section 
     1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(B)).
       (2) Revision and report.--Not later than January 1, 2011, 
     the Secretary shall--
       (A) as appropriate, revise such policies that constrain the 
     ability of the Secretary to respond to emergency situations 
     and situations involving institutional and program closure; 
     and
       (B) in the case where the Secretary determines legislative 
     action is necessary to make such revisions, submit to 
     Congress a report containing recommendations for such 
     legislative action.

     SEC. 106. AUTHORITY TO INCLUDE COSTS OF TRAINING OF 
                   PSYCHOLOGISTS IN PAYMENTS TO HOSPITALS FOR 
                   APPROVED EDUCATIONAL ACTIVITIES UNDER MEDICARE.

       Effective for cost reporting periods beginning on or after 
     the date that is 18 months after the date of enactment of 
     this Act, for purposes of payment to hospitals under the 
     Medicare program under title XVIII of the Social Security Act 
     for costs of approved educational activities (as defined in 
     section 413.85 of title 42, Code of Federal Regulations), 
     such approved educational activities shall include a 1-year 
     doctoral clinical internship operated by the hospital as part 
     of a clinical psychology training program that is provided 
     upon completion of university course work.

         TITLE II--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

     SEC. 201. EXPANSION OF NATIONAL HEALTH SERVICE CORPS 
                   PROGRAMS.

       (a) In General.--Section 338H of the Public Health Service 
     Act (42 U.S.C. 254q) is amended--
       (1) in subsection (a), by striking paragraphs (1) through 
     (5) and inserting the following:
       ``(1) for fiscal year 2009, $165,000,000;
       ``(2) for fiscal year 2010, $198,000,000;
       ``(3) for fiscal year 2011, $231,000,000;
       ``(4) for fiscal year 2012, $264,000,000;
       ``(5) for fiscal year 2013, $297,000,000; and
       ``(6) for fiscal year 2014, $330,000,000.''; and
       (2) by adding at the end the following:
       ``(d) Expansion of Programs.--The Secretary shall use 
     amounts appropriated for each of fiscal years 2010 through 
     2014 under subsection (a), that are in excess of the amount 
     appropriated under such subsection for fiscal year 2009, to 
     address shortages of health professionals in rural, frontier, 
     and urban underserved areas through an expansion of the 
     number of scholarships and loan repayments under this subpart 
     to address health workforce shortages in health professional 
     shortage areas (as defined in section 332), in medically 
     underserved communities (as defined in section 799B), or with 
     respect to medically underserved populations (as defined in 
     section 330(b)(3)).''.
       (b) Expansion of Other Programs.--The Director of the 
     Indian Health Service, the Secretary of Defense, and the 
     Secretary of Veterans Affairs, shall expand existing loan 
     repayment programs to emphasize the provision of health 
     professions services to facilities that have health 
     professional shortages.
       (c) No Tax Implications.--
       (1) In general.--For purposes of the Internal Revenue Code 
     of 1986, any amount received under a health-related Federal 
     loan repayment program by a health professional providing 
     health-related services in a Federal medical facility shall 
     not be included in the gross income of such professional.
       (2) Definition.--In this subsection, the term ``Federal 
     medical facility'' means a facility for the delivery of 
     health services, and includes--
       (A) a federally qualified health center (as defined in 
     section 330A of the Public Health Service Act (42 U.S.C. 
     254c)), a public health center, an outpatient medical 
     facility, or a community mental health center;
       (B) a hospital, State mental hospital, facility for long-
     term care, or rehabilitation facility;
       (C) a migrant health center or an Indian Health Service 
     facility;
       (D) a facility for the delivery of health services to 
     inmates in a penal or correctional institution (under section 
     323 of such Act (42 U.S.C. 250)) or a State correctional 
     institution;
       (E) a Public Health Service medical facility (used in 
     connection with the delivery of health services under section 
     320, 321, 322, 324, 325, or 326 of such Act (42 U.S.C. 247e, 
     248, 249, 251, 252, or 253));
       (F) a nurse-managed health center; or
       (G) any other Federal medical facility.
       (d) Reduced Loan Support for Part Time Practitioners.--
     Section 338C of the Public Health Service Act (42 U.S.C. 
     254m) is amended by adding at the end the following:
       ``(e) Notwithstanding any other provision of this subpart, 
     the Secretary shall develop procedures to permit periods of 
     obligated services to be provided on a part-time basis (not 
     less than 1,040 hours of such service per year). Such 
     procedures shall prohibit an individual from holding other 
     part-time employment while providing such part-time obligated 
     services. The Secretary may provide for a reduction in the 
     loan repayments provided to individuals who provide part-time 
     obligated services under the authority provided under this 
     subsection.''.
       (e) Loan Support for Participating Preceptors, Mentors, and 
     Attendings to Supervise Students and Trainees On-Site.--
     Section 338C of the Public Health Service Act (42 U.S.C. 
     254m), as amended by subsection (d), is further amended by 
     adding at the end the following:
       ``(f) The Secretary shall develop procedures to permit up 
     to 20 percent of the service obligation of an individual 
     under this section to be provided by the individual through 
     precepting or mentoring activities, or by preparing 
     curriculum, for on-site students and trainees. The procedures 
     developed under subsection (e) shall provide for the 
     proportional application of this subsection with respect to 
     individual providing obligated service on a part-time 
     basis.''.

     SEC. 202. NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM 
                   FOR MEDICAL, DENTAL, PHYSICIAN ASSISTANT, 
                   PHARMACY, BEHAVIORAL AND MENTAL HEALTH, PUBLIC 
                   HEALTH, AND NURSING STUDENTS IN THE UNITED 
                   STATES PUBLIC HEALTH SCIENCES TRACK IN 
                   AFFILIATED SCHOOLS.

       (a) Program Authorized.--
       (1) In general.--Subpart III of part D of title III of the 
     Public Health Service Act (42 U.S.C. 254l et seq.) is 
     amended--
       (A) in the heading by inserting ``, Scholarship Program for 
     Medical, Dental, Physician Assistant, Pharmacy, Behavioral 
     and Mental Health, Public Health, and Nursing Students in the 
     United States Public Health Sciences Track in Affiliated 
     Schools,'' after ``Scholarship Program''; and
       (B) by inserting after section 338A the following:

     ``SEC. 338A-1. NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP 
                   PROGRAM FOR MEDICAL, DENTAL, PHYSICIAN 
                   ASSISTANT, PHARMACY, BEHAVIORAL AND MENTAL 
                   HEALTH, PUBLIC HEALTH, AND NURSING STUDENTS IN 
                   THE UNITED STATES PUBLIC HEALTH SCIENCES TRACK 
                   IN AFFILIATED SCHOOLS.

       ``(a) Establishment.--
       ``(1) In general.--The Secretary shall establish a program 
     to be known as the National Health Service Corps Scholarship 
     Program for Medical, Dental, Physician Assistant, Pharmacy, 
     Behavioral and Mental Health, Public Health, and Nursing 
     Students in the United States Public Health Sciences Track in 
     Affiliated Schools (in this section referred to as the `U.S. 
     Public Health Sciences Track Scholarship Program) to ensure, 
     with respect to the provision of high-needs health care 
     services, including primary care, general dentistry, nursing, 
     obstetrics, and geriatricians pursuant to section 331(a)(2), 
     an adequate supply of physicians, physician assistants, 
     pharmacists, behavioral and mental health professionals, 
     public health professionals, dentists, and nurses. The 
     purpose of this program is to train an additional 150 medical 
     students, 100 dental students, 100 physician assistant 
     students, 100 behavioral and mental health students, 100 
     public health students, and 250 nursing students during each 
     year. Of the 150 scholarships awarded to the medical students 
     as described under the preceding sentence, 10 shall be for 
     training at the Uniformed Services University of the Health 
     Sciences as members of the Commissioned Corps of the Public 
     Health Service.
       ``(2) Relationship to national health service corps 
     scholarship program.--

[[Page S4327]]

     Scholarships provided under this section are intended to 
     complement, and not take the place of, scholarships provided 
     to students enrolled in courses of study leading to a degree 
     in medicine, osteopathic medicine, dentistry, or nursing or 
     completion of an accredited physician assistant, pharmacy, 
     public health, or behavioral and mental health educational 
     program under the National Health Service Corps Scholarship 
     Program authorized by section 338A.
       ``(b) Eligibility.--To be eligible to participate in the 
     U.S. Public Health Sciences Track Scholarship and Grants 
     Program, an individual shall--
       ``(1) be accepted for enrollment as a full-time student--
       ``(A) in an accredited (as determined by the Secretary) 
     educational institution in a State; and
       ``(B) in a course of study, or program, offered by such 
     institution leading to a degree in medicine, osteopathic 
     medicine, dentistry, physician assistant, pharmacy, 
     behavioral and mental health, public health, or nursing;
       ``(2) be eligible for, or hold, an appointment as a 
     commissioned officer in the Regular or Reserve Corps of the 
     Service or be eligible for selection for civilian service in 
     the Corps;
       ``(3) submit an application to participate in the U.S. 
     Public Health Sciences Track Scholarship and Grants Program; 
     and
       ``(4) sign and submit to the Secretary, at the time of 
     submittal of such application, a written contract to accept 
     payment of a scholarship and to serve (in accordance with 
     this subpart) for the applicable period of obligated service 
     in an area in which the need for public health-related 
     services may be demonstrated.''.
       (2) No tax implications.--For purposes of the Internal 
     Revenue Code of 1986, any amount received under the National 
     Health Service Corps Scholarship Program for Medical, Dental 
     and Nursing Students in the United States Public Health 
     Sciences Track in Affiliated Schools under section 338A-1 of 
     the Public Health Service Act, as added by paragraph (1), by 
     a medical student, dental student, or nursing student shall 
     not be included in the gross income of such student.
       (b) Grants to Increase the Number of Available Slots for 
     Newly Admitted Medical, Dental, Physician Assistant, 
     Pharmacy, Behavioral and Mental Health, Public Health, and 
     Nursing Students and to Increase Participation in the U.S. 
     Public Health Sciences Track Scholarship Program.--Part C of 
     title VII of the Public Health Service Act (42 U.S.C. 293k et 
     seq.) is amended by adding at the end the following:

     ``SEC. 749. GRANTS TO INCREASE THE NUMBER OF AVAILABLE SLOTS 
                   FOR NEWLY ADMITTED MEDICAL, DENTAL, PHYSICIAN 
                   ASSISTANT, PHARMACY, BEHAVIORAL AND MENTAL 
                   HEALTH, PUBLIC HEALTH, AND NURSING STUDENTS AND 
                   TO INCREASE PARTICIPATION IN THE U.S. PUBLIC 
                   HEALTH SCIENCES TRACK SCHOLARSHIP PROGRAM.

       ``(a) Program Authorized.--The Secretary may make grants to 
     medical, dental, public health, and nursing schools and 
     physician assistant, pharmacy, and behavioral and mental 
     health programs for the following purposes:
       ``(1) To increase the capacity of the recipient medical, 
     dental, public health, or nursing school or physician 
     assistant, pharmacy, or behavioral and mental health program, 
     to accept additional medical, dental, public health, nursing, 
     physician assistant, pharmacy, or behavioral and mental 
     health students each year.
       ``(2) To develop curriculum.
       ``(3) To acquire equipment.
       ``(4) To recruit, train, and retain faculty.
       ``(5) To provide assistance to students who have completed 
     a course of study at the recipient medical, dental, public 
     health, or nursing school or physician assistant, pharmacy, 
     or behavioral and mental health program during the period in 
     which such students are completing a residency or internship 
     program affiliated with the recipient institution.
       ``(b) Application.--A medical, dental, public health, or 
     nursing school or physician assistant, pharmacy, or 
     behavioral and mental health program seeking a grant under 
     this section shall submit an application to the Secretary at 
     such time, in such manner, and containing such information as 
     the Secretary may require.
       ``(c) Definition of Medical School.--In this section, the 
     term `medical school' means a school of medicine or a school 
     of osteopathic medicine.''.

     SEC. 203. FEDERAL MEDICAL FACILITY GRANT PROGRAM AND PROGRAM 
                   ASSESSMENTS.

       (a) Federal Medical Facility Grant Program.--Title VII of 
     the Public Health Service Act (42 U.S.C. 292 et seq.) is 
     amended--
       (1) by redesignating part F as part G; and
       (2) by inserting after part E, the following:

``PART F--START-UP EXPENSES LOAN AND GRANT PROGRAMS FOR FEDERAL MEDICAL 
  FACILITIES AND HOSPITALS STARTING HIGH NEEDS RESIDENCY PROGRAMS IN 
                             SHORTAGE AREAS

     ``SEC. 781. FEDERAL MEDICAL FACILITY GRANT PROGRAM.

       ``(a) In General.--The Secretary shall award grants to 
     eligible facilities to increase interdisciplinary, community-
     based health professions training in high-needs specialties 
     for physicians, nurses, dentists, physician assistants, 
     pharmacy, behavioral and mental health professionals, public 
     health professionals, and other health professionals as 
     determined appropriate by the Secretary, in consultation with 
     the Permanent National Health Workforce Commission 
     established under section 101(a) of the Health Access and 
     Health Professions Supply Act of 2009.
       ``(b) Eligible Facilities; Application.--
       ``(1) Definition of eligible facility.--In this section, 
     the term `eligible facility'--
       ``(A) means a facility which--
       ``(i) is located in a health professional shortage area (as 
     defined in section 332);
       ``(ii) is located in a medically underserved community (as 
     defined in section 799B), or with respect to a medically 
     underserved population (as defined in section 330(b)(3));
       ``(iii) is a Federal medical facility;
       ``(iv) is an area health education center, a health 
     education and training center, or a participant in the 
     Quentin N. Burdick program for rural interdisciplinary 
     training, that meet the requirements established by the 
     Secretary; or
       ``(v) is establishing new residency programs in a specialty 
     which the Secretary, in consultation with the Permanent 
     National Health Workforce Commission established under 
     section 101(a) of the Health Access and Health Professions 
     Supply Act of 2009, determines is in high-need; and
       ``(B) includes Medicare certified Federally Qualified 
     Health Centers, community health centers, health care for the 
     homeless centers, rural health centers, migrant health 
     centers, Indian Health Service entities, urban Indian 
     centers, health clinics and hospitals operated by the Indian 
     Health Service, Indian tribes and tribal organizations, and 
     urban Indian organizations (as defined in section 4 of the 
     Indian Health Care Improvement Act), and other Federal 
     medical facilities).
       ``(2) Application.--An eligible facility desiring a grant 
     under subsection (a) shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(c) Use of Funds.--An eligible facility shall use amounts 
     received under a grant under subsection (a) to promote--
       ``(1) the training of health professionals in 
     interdisciplinary, community-based settings that are 
     affiliated with hospitals and other health care facilities 
     and teaching institutions;
       ``(2) community development programs that assure a diverse 
     health professions workforce through emphasis on individuals 
     from rural and frontier areas and underrepresented minority 
     groups;
       ``(3) the development of a reliable health professions 
     pipeline that provides an emphasis on health-related careers 
     in schools (such as schools participating in the Health 
     Careers Opportunities Program) and centers of excellence, and 
     that encourage individuals in underrepresented minorities 
     (including Hispanic, African American, American Indian, and 
     Alaska Native individuals) to pursue health professions 
     careers;
       ``(4) the reduction of health professional isolation in 
     rural, frontier, and urban underserved areas through the 
     provision of continuing education, mentoring, and precepting 
     activities, field faculty development, and the utilization of 
     technology such as telehealth and electronic health records;
       ``(5) the establishment and operation of regional or 
     statewide health advice telephone lines to reduce after-hours 
     call responsibilities for overworked health professionals who 
     provide services in remote areas that have few health 
     professionals taking such after-hours calls;
       ``(6) an increase in the number of professionals taking 
     after-hours calls in hospitals and emergency departments in 
     health professional shortage areas (as defined in section 
     332), in medically underserved communities (as defined in 
     section 799B), or with respect to medically underserved 
     populations (as defined in section 330(b)(3));
       ``(7) the establishment and operation of relief programs 
     that provide health professionals practicing in health 
     professional shortage areas (as defined in section 332) with 
     patient and call coverage when such professionals are ill, 
     are pursuing continuing education, or are taking a vacation; 
     and
       ``(8) the exposure of health professions residents to 
     systems of health care that represent the contemporary 
     American healthcare delivery program (such as `P4' Prepare 
     the Personal Physician for Practice and the `Health Commons' 
     programs).
       ``(d) Subgrants.--An eligible facility may use amounts 
     received under a grant under this section to award subgrants 
     to States and other entities determined appropriate by the 
     Secretary to carry out the activities described in subsection 
     (c).
       ``(e) Set Aside.--In awarding grants under this section, 
     the Secretary shall ensure that a total of $500,000 is 
     awarded annually for the activities of the National Rural 
     Recruitment and Retention Network, or a similar entity.
       ``(f) Definition of Federal Medical Facility.--In this 
     section, the term `Federal medical facility' means a facility 
     for the delivery of health services, and includes--
       ``(1) a federally qualified health center (as defined in 
     section 330A), a public health center, an outpatient medical 
     facility, or a community mental health center;
       ``(2) a hospital, State mental hospital, facility for long-
     term care, or rehabilitation facility;
       ``(3) a migrant health center or an Indian Health Service 
     facility;
       ``(4) a facility for the delivery of health services to 
     inmates in a penal or correctional

[[Page S4328]]

     institution (under section 323) or a State correctional 
     institution;
       ``(5) a Public Health Service medical facility (used in 
     connection with the delivery of health services under section 
     320, 321, 322, 324, 325, or 326)); or
       ``(6) any other Federal medical facility.
       ``(g) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $623,000,000 for fiscal year 2009, $666,000,000 for fiscal 
     year 2010, $675,000,000 for fiscal year 2011, $700,000,000 
     for fiscal year 2012, and $725,000,000 for fiscal year 
     2013.''.
       (b) Assessments.--
       (1) Establishment.--The Secretary of Health and Human 
     Services (referred to in this section as the ``Secretary'') 
     shall establish program assessment rating tools for each 
     program funded through titles VII and VIII of the Public 
     Health Service Act (42 U.S.C. 292 and 296 et seq.).
       (2) Criteria.--The Secretary, in consultation with the 
     Administrator of the Health Resources and Services 
     Administration and other appropriate public and private 
     stakeholders, shall, through negotiated rulemaking, establish 
     criteria for the conduct of the assessments under paragraph 
     (2).
       (3) Annual assessments.--The Secretary shall annually enter 
     into a contract with an independent nongovernmental entity 
     for the conduct of an assessment, using the tools established 
     under paragraph (1) and the criteria established under 
     paragraph (2), of not less than 20 percent, nor more than 25 
     percent, of the programs carried out under titles VII and 
     VIII of the Public Health Service Act, so that every program 
     under such titles is assessed at least once during every 5-
     year period.

     SEC. 204. HEALTH PROFESSIONS TRAINING LOAN PROGRAM.

       Part F of title VII of the Public Health Service Act (as 
     added by section 203) is amended by adding at the end the 
     following

     ``SEC. 782. ESTABLISHMENT.

       ``(a) In General.--The Secretary shall establish a program 
     under which the Secretary shall award interest-free loans 
     to--
       ``(1) eligible hospitals to enable such hospitals to 
     establish training programs in high-need specialties; and
       ``(2) eligible non-hospital community-based entities to 
     enable such entities to establish health professions training 
     programs.
       ``(b) Eligibility.--
       ``(1) In general.--To be eligible to receive a loan under 
     subsection (a)--
       ``(A) a hospital shall--
       ``(i) be located in a health professional shortage area (as 
     such term is defined in section 332);
       ``(ii) comply with the requirements of paragraph (2); and
       ``(iii) submit to the Secretary an application at such 
     time, in such manner, and containing such information as the 
     Secretary may require; or
       ``(B) a non-hospital community-based entity shall--
       ``(i) comply with the requirements of paragraph (2); and
       ``(ii) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(2) Requirements.--To be eligible to receive a loan under 
     subsection (a), a hospital or non-hospital community-based 
     entity shall--
       ``(A) on the date on which the entity submits the loan 
     application, not operate a residency with respect to a high-
     needs specialty (as determined by the Secretary in 
     consultation with the Permanent National Health Workforce 
     Commission established under section 101(a) of the Health 
     Access and Health Professions Supply Act of 2009) or provide 
     a health professions training program, as the case may be;
       ``(B) have received appropriate preliminary accreditation 
     from the relevant accrediting agency (American Council for 
     Graduate Medical Education, American Osteopathic Association, 
     or Dental, Physician Assistant, Pharmacy, Behavioral and 
     Mental Health, Public Health, and Nursing accrediting 
     agencies), as determined by the Secretary; and
       ``(C) execute a signed formal contract under which the 
     hospital or entity agree to repay the loan.
       ``(c) Use of Loan Funds.--Amounts received under a loan 
     under subsection (a) shall be used only for--
       ``(1) the salary and fringe benefit expenses of residents, 
     students, trainees, and faculty, or other costs directly 
     attributable to the residency, educational, or training 
     program to be carried out under the loan, as specified by the 
     Secretary; or
       ``(2) facility construction or renovation, including 
     equipment purchase.
       ``(d) Priority.--In awarding loans under subsection (a), 
     the Secretary shall give priority to applicants that are 
     located in health professional shortage areas (as defined in 
     section 332) or in medically underserved communities (as 
     defined in section 799B), or that serve medically underserved 
     populations (as defined in section 330(b)(3)).
       ``(e) Loan Provisions.--
       ``(1) Loan contract.--The loan contract entered into under 
     subsection (b)(2) shall contain terms that provide for the 
     repayment of the loan, including the number and amount of 
     installment payments as described in such contract. Such 
     repayment shall begin on the date that is 24 months after the 
     date on which the loan contract is executed and shall be 
     fully repaid not later than 36 months after the date of the 
     first payment.
       ``(2) Interest.--Loans under this section shall be repaid 
     without interest.
       ``(f) Limitation.--The amount of a loan under this section 
     with respect to each of the uses described in subsection 
     (c)(1) or (c)(2) shall not exceed $2,000,000.
       ``(g) Failure to Repay.--A hospital or non-hospital 
     community-based entity that fails to comply with the terms of 
     a contract entered into under subsection (b)(2) shall be 
     liable to the United States for the amount which has been 
     paid to such hospital or entity under the contract.
       ``(h) Authorization of Appropriations.--There is authorized 
     to be appropriated, such sums as may be necessary to carry 
     out this section.''.

     SEC. 205. UNITED STATES PUBLIC HEALTH SCIENCES TRACK.

       Title II of the Public Health Service Act (42 U.S.C. 202 et 
     seq.) is amended by adding at the end the following:

          ``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK

     ``SEC. 271. ESTABLISHMENT.

       ``(a) United States Public Health Services Track.--
       ``(1) In general.--There is hereby authorized to be 
     established a United States Public Health Sciences Track 
     (referred to in this part as the `Track'), at sites to be 
     selected by the Secretary, with authority to grant 
     appropriate advanced degrees in a manner that uniquely 
     emphasizes team-based service, public health, epidemiology, 
     and emergency preparedness and response. It shall be so 
     organized as to graduate not less than--
       ``(A) 150 medical students annually;
       ``(B) 100 dental students annually;
       ``(C) 250 nursing students annually;
       ``(D) 100 public health students annually;
       ``(E) 100 behavioral and mental health professional 
     students annually;
       ``(F) 100 physician assistant or nurse practitioner 
     students annually; and
       ``(G) 50 pharmacy students annually.
       ``(2) Locations.--The Track shall be located at existing 
     and accredited, affiliated health professions education 
     training programs at academic health centers located in 
     regions of the United States determined appropriate by the 
     Surgeon General, in consultation with the Permanent National 
     Health Workforce Commission.
       ``(b) Number of Graduates.--Except as provided in 
     subsection (a), the number of persons to be graduated from 
     the Track shall be prescribed by the Secretary. In so 
     prescribing the number of persons to be graduated from the 
     Track, the Secretary shall institute actions necessary to 
     ensure the maximum number of first-year enrollments in the 
     Track consistent with the academic capacity of the affiliated 
     sites and the needs of the United States for medical, dental, 
     and nursing personnel.
       ``(c) Development.--The development of the Track may be by 
     such phases as the Secretary may prescribe subject to the 
     requirements of subsection (a).
       ``(d) Integrated Longitudinal Plan.--The Surgeon General 
     shall develop an integrated longitudinal plan for health 
     professions continuing education throughout the continuum of 
     health-related education, training, and practice. Training 
     under such plan shall emphasize patient-centered, 
     interdisciplinary, and care coordination skills. Experience 
     with deployment of emergency response teams shall be included 
     during the clinical experiences.
       ``(e) Faculty Development.--The Surgeon General shall 
     develop faculty development programs and curricula in 
     decentralized venues of health care, to balance urban, 
     tertiary, and inpatient venues.

     ``SEC. 272. ADMINISTRATION.

       ``(a) In General.--The business of the Track shall be 
     conducted by the Surgeon General with funds appropriated for 
     and provided by the Department of Health and Human Services. 
     The Permanent National Health Workforce Commission shall 
     assist the Surgeon General in an advisory capacity.
       ``(b) Faculty.--
       ``(1) In general.--The Surgeon General, after considering 
     the recommendations of the Permanent National Health 
     Workforce Commission, shall obtain the services of such 
     professors, instructors, and administrative and other 
     employees as may be necessary to operate the Track, but 
     utilize when possible, existing affiliated health professions 
     training institutions. Members of the faculty and staff shall 
     be employed under salary schedules and granted retirement and 
     other related benefits prescribed by the Secretary so as to 
     place the employees of the Track faculty on a comparable 
     basis with the employees of fully accredited schools of the 
     health professions within the United States.
       ``(2) Titles.--The Surgeon General may confer academic 
     titles, as appropriate, upon the members of the faculty.
       ``(3) Nonapplication of provisions.--The limitations in 
     section 5373 of title 5, United States Code, shall not apply 
     to the authority of the Surgeon General under paragraph (1) 
     to prescribe salary schedules and other related benefits.
       ``(c) Agreements.--The Surgeon General may negotiate 
     agreements with agencies of the Federal Government to utilize 
     on a reimbursable basis appropriate existing Federal medical 
     resources located in the United States (or locations selected 
     in accordance with section 271(a)(2)). Under such agreements 
     the facilities concerned will retain

[[Page S4329]]

     their identities and basic missions. The Surgeon General may 
     negotiate affiliation agreements with accredited universities 
     and health professions training institutions in the United 
     States. Such agreements may include provisions for payments 
     for educational services provided students participating in 
     Department of Health and Human Services educational programs.
       ``(d) Programs.--The Surgeon General may establish the 
     following educational programs for Track students:
       ``(1) Postdoctoral, postgraduate, and technological 
     institutes.
       ``(2) A graduate school of nursing.
       ``(3) Other schools or programs that the Surgeon General 
     determines necessary in order to operate the Track in a cost-
     effective manner.
       ``(e) Continuing Medical Education.--The Surgeon General 
     shall establish programs in continuing medical education for 
     members of the health professions to the end that high 
     standards of health care may be maintained within the United 
     States.
       ``(f) Authority of the Surgeon General.--
       ``(1) In general.--The Surgeon General is authorized--
       ``(A) to enter into contracts with, accept grants from, and 
     make grants to any nonprofit entity for the purpose of 
     carrying out cooperative enterprises in medical, dental, 
     physician assistant, pharmacy, behavioral and mental health, 
     public health, and nursing research, consultation, and 
     education;
       ``(B) to enter into contracts with entities under which the 
     Surgeon General may furnish the services of such 
     professional, technical, or clerical personnel as may be 
     necessary to fulfill cooperative enterprises undertaken by 
     the Track;
       ``(C) to accept, hold, administer, invest, and spend any 
     gift, devise, or bequest of personal property made to the 
     Track, including any gift, devise, or bequest for the support 
     of an academic chair, teaching, research, or demonstration 
     project;
       ``(D) to enter into agreements with entities that may be 
     utilized by the Track for the purpose of enhancing the 
     activities of the Track in education, research, and 
     technological applications of knowledge; and
       ``(E) to accept the voluntary services of guest scholars 
     and other persons.
       ``(2) Limitation.--The Surgeon General may not enter into 
     any contract with an entity if the contract would obligate 
     the Track to make outlays in advance of the enactment of 
     budget authority for such outlays.
       ``(3) Scientists.--Scientists or other medical, dental, or 
     nursing personnel utilized by the Track under an agreement 
     described in paragraph (1) may be appointed to any position 
     within the Track and may be permitted to perform such duties 
     within the Track as the Surgeon General may approve.
       ``(4) Volunteer services.--A person who provides voluntary 
     services under the authority of subparagraph (E) of paragraph 
     (1) shall be considered to be an employee of the Federal 
     Government for the purposes of chapter 81 of title 5, 
     relating to compensation for work-related injuries, and to be 
     an employee of the Federal Government for the purposes of 
     chapter 171 of title 28, relating to tort claims. Such a 
     person who is not otherwise employed by the Federal 
     Government shall not be considered to be a Federal employee 
     for any other purpose by reason of the provision of such 
     services.

     ``SEC. 273. STUDENTS; SELECTION; OBLIGATION.

       ``(a) Student Selection.--
       ``(1) In general.--Medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, and 
     nursing students at the Track shall be selected under 
     procedures prescribed by the Surgeon General. In so 
     prescribing, the Surgeon General shall consider the 
     recommendations of the Permanent National Health Workforce 
     Commission.
       ``(2) Priority.--In developing admissions procedures under 
     paragraph (1), the Surgeon General shall ensure that such 
     procedures give priority to applicant medical, dental, 
     physician assistant, pharmacy, behavioral and mental health, 
     public health, and nursing students from rural communities 
     and underrepresented minorities.
       ``(b) Contract and Service Obligation.--
       ``(1) Contract.--Upon being admitted to the Track, a 
     medical, dental, physician assistant, pharmacy, behavioral 
     and mental health, public health, or nursing student shall 
     enter into a written contract with the Surgeon General that 
     shall contain--
       ``(A) an agreement under which--
       ``(i) subject to subparagraph (B), the Surgeon General 
     agrees to provide the student with tuition (or tuition 
     remission) and a student stipend (described in paragraph (2)) 
     in each school year for a period of years (not to exceed 4 
     school years) determined by the student, during which period 
     the student is enrolled in the Track at an affiliated or 
     other participating health professions institution pursuant 
     to an agreement between the Track and such institution; and
       ``(ii) subject to subparagraph (B), the student agrees--

       ``(I) to accept the provision of such tuition and student 
     stipend to the student;
       ``(II) to maintain enrollment at the Track until the 
     student completes the course of study involved;
       ``(III) while enrolled in such course of study, to maintain 
     an acceptable level of academic standing (as determined by 
     the Surgeon General);
       ``(IV) if pursuing a degree from a school of medicine or 
     osteopathic medicine, dental, public health, or nursing 
     school or a physician assistant, pharmacy, or behavioral and 
     mental health professional program, to complete a residency 
     or internship in a specialty that the Surgeon General 
     determines is appropriate; and
       ``(V) to serve for a period of time (referred to in this 
     part as the `period of obligated service') within the 
     Commissioned Corps of the Public Health Service equal to 2 
     years for each school year during which such individual was 
     enrolled at the College, reduced as provided for in paragraph 
     (3);

       ``(B) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this part and any obligation of the student which is 
     conditioned thereon, is contingent upon funds being 
     appropriated to carry out this part;
       ``(C) a statement of the damages to which the United States 
     is entitled for the student's breach of the contract; and
       ``(D) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     the provisions of this part.
       ``(2) Tuition and student stipend.--
       ``(A) Tuition remission rates.--The Surgeon General, based 
     on the recommendations of the Permanent National Health 
     Workforce Commission established under section 101(a) of the 
     Health Access and Health Professions Supply Act of 2009, 
     shall establish Federal tuition remission rates to be used by 
     the Track to provide reimbursement to affiliated and other 
     participating health professions institutions for the cost of 
     educational services provided by such institutions to Track 
     students. The agreement entered into by such participating 
     institutions under paragraph (1)(A)(i) shall contain an 
     agreement to accept as payment in full the established 
     remission rate under this subparagraph.
       ``(B) Stipend.--The Surgeon General, based on the 
     recommendations of the Permanent National Health Workforce 
     Commission, shall establish and update Federal stipend rates 
     for payment to students under this part.
       ``(3) Reductions in the period of obligated service.--The 
     period of obligated service under paragraph (1)(A)(ii)(V) 
     shall be reduced--
       ``(A) in the case of a student who elects to participate in 
     a high-needs speciality residency (as determined by the 
     Permanent National Health Workforce Commission), by 3 months 
     for each year of such participation (not to exceed a total of 
     12 months); and
       ``(B) in the case of a student who, upon completion of 
     their residency, elects to practice in a Federal medical 
     facility (as defined in section 781(e)) that is located in a 
     health professional shortage area (as defined in section 
     332), by 3 months for year of full-time practice in such a 
     facility (not to exceed a total of 12 months).
       ``(c) Second 2 Years of Service.--During the third and 
     fourth years in which a medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, or 
     nursing student is enrolled in the Track, training should be 
     designed to prioritize clinical rotations in Federal medical 
     facilities in health professional shortage areas, and 
     emphasize a balance of hospital and community-based 
     experiences, and training within interdisciplinary teams.
       ``(d) Dentist, Physician Assistant, Pharmacist, Behavioral 
     and Mental Health Professional, Public Health Professional, 
     and Nurse Training.--The Surgeon General shall establish 
     provisions applicable with respect to dental, physician 
     assistant, pharmacy, behavioral and mental health, public 
     health, and nursing students that are comparable to those for 
     medical students under this section, including service 
     obligations, tuition support, and stipend support. The 
     Surgeon General shall give priority to health professions 
     training institutions that train medical, dental, physician 
     assistant, pharmacy, behavioral and mental health, public 
     health, and nursing students for some significant period of 
     time together, but at a minimum have a discrete and shared 
     core curriculum.
       ``(e) Elite Federal Disaster Teams.--The Surgeon General, 
     in consultation with the Secretary, the Director of the 
     Centers for Disease Control and Prevention, and other 
     appropriate military and Federal government agencies, shall 
     develop criteria for the appointment of highly qualified 
     Track faculty, medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, and 
     nursing students, and graduates to elite Federal disaster 
     preparedness teams to train and to respond to public health 
     emergencies, natural disasters, bioterrorism events, and 
     other emergencies.
       ``(f) Student Dropped From Track in Affiliate School.--A 
     medical, dental, physician assistant, pharmacy, behavioral 
     and mental health, public health, or nursing student who, 
     under regulations prescribed by the Surgeon General, is 
     dropped from the Track in an affiliated school for deficiency 
     in conduct or studies, or for other reasons, shall be liable 
     to the United States for all tuition and stipend support 
     provided to the student.

     ``SEC. 274. AUTHORIZATION OF APPROPRIATIONS.

       ``There is authorized to be appropriated to carry out this 
     part, section 338A-1, and section 749, such sums as may be 
     necessary.''.

     SEC. 206. MEDICAL EDUCATION DEBT REIMBURSEMENT FOR PHYSICIANS 
                   OF THE VETERANS HEALTH ADMINISTRATION.

       (a) In General.--The Secretary of Veterans Affairs shall 
     carry out a program

[[Page S4330]]

     under which eligible physicians described in subsection (b) 
     are reimbursed for the education debt of such physicians as 
     described in subsection (c).
       (b) Eligible Physicians.--An eligible physician described 
     in this subsection is any physician currently appointed to a 
     physician position in the Veterans Health Administration 
     under section 7402(b)(1) of title 38, United States Code, who 
     enters into an agreement with the Secretary to continue 
     serving as a physician in such position for such period of 
     time as the Secretary shall specify in the agreement.
       (c) Covered Education Debt.--The education debt for which 
     an eligible physician may be reimbursed under this section is 
     any amount paid by the physician for tuition, room and board, 
     or expenses in obtaining the degree of doctor or medicine or 
     of doctor of osteopathy, including any amounts of principal 
     or interest paid by the physician under a loan, the proceeds 
     of which were used by or on behalf of the physician for the 
     costs of obtaining such degree.
       (d) Frequency of Reimbursement.--Any reimbursement of an 
     eligible physician under this section shall be made in a lump 
     sum or in installments of such frequency as the Secretary 
     shall specify the agreement of the physician as required 
     under subsection (b).
       (e) Liability for Failure to Complete Obligated Service.--
     Any eligible physician who fails to satisfactorily complete 
     the period of service agreed to by the physician under 
     subsection (b) shall be liable to the United States in an 
     amount determined in accordance with the provisions of 
     section 7617(c)(1) of title 38, United States Code.
       (f) Treatment of Reimbursement With Other Pay and Benefit 
     Authorities.--Any amount of reimbursement payable to an 
     eligible physician under this section is in addition to any 
     other pay, allowances, or benefits that may be provided the 
     physician under law, including any educational assistance 
     under the Department of Veterans Affairs Health Professional 
     Educational Assistance Program under chapter 76 of title 38, 
     United States Code.

 TITLE III--HEALTH PROFESSIONAL TRAINING PIPELINE PARTNERSHIPS PROGRAM

     SEC. 301. GRANTS TO PREPARE STUDENTS FOR CAREERS IN HEALTH 
                   CARE.

       (a) Purpose.--The purpose of this section is to support the 
     development and implementation of programs designed to 
     prepare middle school and high school students for study and 
     careers in the healthcare field, including success in 
     postsecondary mathematics and science programs.
       (b) Definitions.--In this section:
       (1) Children from low-income families.--The term ``children 
     from low-income families'' means children described in 
     section 1124(c)(1)(A) of the Elementary and Secondary 
     Education Act of 1965 (20 U.S.C. 6333(c)(1)(A)).
       (2) Eligible recipients.--The term ``eligible recipient'' 
     means--
       (A) a nonprofit healthcare career pathway partnership 
     organization; or
       (B) a high-need local educational agency in partnership 
     with--
       (i) not less than 1 institution of higher education with an 
     established health profession education program; and
       (ii) not less than 1 community-based, private sector 
     healthcare provider organization.
       (3) High-need local educational agency.--The term ``high-
     need local educational agency'' means a local educational 
     agency or educational service agency--
       (A) that serves not fewer than 10,000 children from low-
     income families;
       (B) for which not less than 20 percent of the children 
     served by the agency are children from low-income families;
       (C) that meets the eligibility requirements for funding 
     under the Small, Rural School Achievement Program under 
     section 6211(b) of the Elementary and Secondary Education Act 
     of 1965 (20 U.S.C. 7345(b)); or
       (D) that meets the eligibility requirements for funding 
     under the Rural and Low-Income School Program under section 
     6221(b)(1) of the Elementary and Secondary Education Act of 
     1965 (20 U.S.C. 7351(b)(1)).
       (4) Nonprofit healthcare career pathway partnership 
     organization.--The term ``nonprofit healthcare career pathway 
     partnership organization'' means a nonprofit organization 
     focused on developing career and educational pathways to 
     healthcare professions, that shall include representatives 
     of--
       (A) the local educational agencies;
       (B) not less than 1 institution of higher education (as 
     defined in section 101(a) of the Higher Education Act of 1965 
     (20 U.S.C. 1001(a))) with an established health profession 
     education program; and
       (C) not less than 1 community-based, private sector 
     healthcare provider organization or other healthcare industry 
     organization.
       (5) Secretary.--The term ``Secretary'' means the Secretary 
     of Education.
       (c) Grants Authorized.--
       (1) In general.--The Secretary is authorized to award 
     grants, on a competitive basis, to eligible recipients to 
     enable the recipients to develop and implement programs of 
     study to prepare middle school and high school students for 
     postsecondary education leading to careers in the healthcare 
     field.
       (2) Minimum funding level.--Grants shall be awarded at a 
     minimum level of $500,000 per recipient, per year.
       (3) Renewability.--Grants may be renewed, at the discretion 
     of the Secretary, for not more than 5 years.
       (d) Application.--Each eligible recipient desiring a grant 
     under this section shall submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require, which shall include 
     an assurance that the recipient will meet the program 
     requirements described in subsection (f)(2).
       (e) Priority.--In awarding grants under this section, the 
     Secretary shall give priority to--
       (1) applicants that include a local educational agency that 
     is located in an area that is designated under section 
     332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 
     254e(a)(1)(A)) as a health professional shortage area;
       (2) applicants that include an institution of higher 
     education that emphasizes an interdisciplinary approach to 
     health profession education; and
       (3) applicants whose program involves the development of a 
     uniquely innovative public-private partnership.
       (f) Authorized Activities/use of Funds.--
       (1) In general.--Each eligible recipient that receives a 
     grant under this section shall use the grant funds to develop 
     and implement programs of study to prepare middle school and 
     high school students for careers in the healthcare field 
     that--
       (A) are aligned with State challenging academic content 
     standards and State challenging student academic achievement 
     standards; and
       (B) lead to high school graduation with the skills and 
     preparation--
       (i) to enter postsecondary education programs of study in 
     mathematics and science without remediation; and
       (ii) necessary to enter healthcare jobs directly.
       (2) Program requirements.--A program of study described in 
     paragraph (1) shall--
       (A) involve a review and identification of the content 
     knowledge and skills students who enter institutions of 
     higher education and the workforce need to have in order to 
     succeed in the healthcare field;
       (B) promote the alignment of mathematics and science 
     curricula and assessments in middle school and high school 
     and facilitate learning of the required knowledge and skills 
     identified in subparagraph (A);
       (C) include an outreach component to educate middle school 
     and high school students and their parents about the full 
     range of employment opportunities in the healthcare field, 
     specifically in the local community;
       (D) include specific opportunities for youth to interact 
     with healthcare professionals or industry representatives in 
     the classroom, school, or community locations and how these 
     experiences will be integrated with coursework;
       (E) include high-quality volunteer or internship 
     experiences, integrated with coursework;
       (F) provide high-quality mentoring, counseling, and career 
     counseling support services to program participants;
       (G) consider the inclusion of a distance-learning component 
     or similar education technology that would expand 
     opportunities for geographically isolated individuals;
       (H) encourage the participation of individuals who are 
     members of groups that are underrepresented in postsecondary 
     education programs in mathematics and science;
       (I) encourage participants to seek work in communities 
     experiencing acute health professional shortages; and
       (J) collect data, and analyze the data using measurable 
     objectives and benchmarks, to evaluate the extent to which 
     the program succeeded in--
       (i) increasing student and parent awareness of occupational 
     opportunities in the healthcare field;
       (ii) improving student academic achievement in mathematics 
     and science;
       (iii) increasing the number of students entering health 
     care professions upon graduation; and
       (iv) increasing the number of students pursuing secondary 
     education or training opportunities with the potential to 
     lead to a career in the healthcare field.
       (3) Planning grant set aside.--Each eligible recipient that 
     receives a grant under this section shall set aside 10 
     percent of the grant funds for planning and program 
     development purposes.
       (g) Matching Requirement.--Each eligible recipient that 
     receives a grant under this section shall provide, from the 
     private sector, an amount equal to 40 percent of the amount 
     of the grant, in cash or in kind, to carry out the activities 
     supported by the grant.
       (h) Reports.--
       (1) Annual evaluation.--Each eligible recipient that 
     receives a grant under this section shall collect and report 
     to the Secretary annually such information as the Secretary 
     may reasonably require, including--
       (A) the number of schools involved and student participants 
     in the program;
       (B) the race, gender, socio-economic status, and disability 
     status of program participants;
       (C) the number of program participants who successfully 
     graduated from high school;
       (D) the number of program participants who reported 
     enrollment in some form of postsecondary education with the 
     potential to lead to a career in the healthcare field;
       (E) the number of program participants who entered a paid 
     position, either part-time

[[Page S4331]]

     or full-time, in the healthcare field following participation 
     in the program; and
       (F) the data and analysis required under subsection 
     (f)(2)(J).
       (2) Report.--Not later than 3 years after the date of 
     enactment of this section, the Secretary shall submit to 
     Congress an interim report on the results of the evaluations 
     conducted under paragraph (1).
       (i) Authorization and Appropriation.--
       (1) In general.--There are authorized to be appropriated 
     $100,000,000 for each of fiscal years 2009 through 2013 to 
     carry out this section.
       (2) Administrative costs.--For the costs of administering 
     this section, including the costs of evaluating the results 
     of grants and submitting reports to the Congress, there are 
     authorized to be appropriated such sums as may be necessary 
     for each of fiscal years 2009 through 2013.
                                 ______