[Congressional Record Volume 155, Number 79 (Thursday, May 21, 2009)]
[Senate]
[Pages S5822-S5874]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. LEAHY (for himself, Mr. Sanders, Mrs. Shaheen, and Mr. 
        Gregg):
  S. 1117. A bill to authorize the Secretary of the Interior to provide 
assistance in implementing cultural heritage, conservation, and 
recreational activities in the Connecticut River watershed of the 
States of New Hampshire

[[Page S5823]]

and Vermont; to the Committee on Energy and Natural Resources.
  Mr. LEAHY. Mr. President, I am pleased to introduce today the Upper 
Connecticut River Partnership Act. This legislation will help bring 
recognition to New England's largest river ecosystem and one of our 
Nation's 14 American Heritage Rivers.
  The purpose of this legislation is to help the communities along the 
river protect and enhance their rich cultural history, economic 
vitality, and the environmental integrity of the river.
  From its origin in the mountains of northern New Hampshire, the 
Connecticut River runs over 400 miles and eventually empties into Long 
Island Sound. The river forms a natural boundary between my home state 
of Vermont and New Hampshire, and travels through the States of 
Massachusetts and Connecticut. The river and surrounding valley have 
long shaped and influenced development in the New England region. This 
river is one of America's earliest developed rivers, with European 
settlements going back over 350 years. The industrial revolution 
blossomed in the Connecticut River Valley, supported by new 
technologies such as canals and mills run by hydropower.
  I am pleased that the entire Senate delegations from Vermont and New 
Hampshire have cosponsored this bill. For years our States have worked 
together, to help communities on both sides of the river develop local 
partnerships to protect the Connecticut River valley of Vermont and New 
Hampshire. While great improvements have been made to the river, its 
overall health remains threatened by water and air pollution, habitat 
loss, hydroelectric dams, and invasive species.
  Historically, the people throughout the Upper Connecticut River 
Valley have functioned cooperatively and the river serves to unite 
Vermont and New Hampshire communities economically, culturally, and 
environmentally.
  Citizens on both sides of the river know just how special this region 
is and have worked side by side for years to protect it. Efforts have 
been underway for some time to restore the Atlantic salmon fishery, 
protect threatened and endangered species, and support urban riverfront 
revitalization.
  In 1989, Vermont and New Hampshire came together to create the 
Connecticut River Joint Commissions--a unique partnership between the 
states, local businesses, all levels of Government within the 2 States 
and citizens from all walks of life. This partnership helps coordinate 
the efforts of towns, watershed managers and other local groups to 
implement the Connecticut River Corridor Management Plan. This Plan has 
become the blueprint for how communities along the river can work with 
one another with Vermont and New Hampshire and with the federal 
government to protect the river's resources.
  The Upper Connecticut River Partnership Act would help carry out the 
recommendations of the Connecticut River Corridor Management Plan, 
which was developed under New Hampshire law with the active 
participation of Vermont citizens and communities.
  This act would also provide the Secretary of the Interior with the 
much needed ability to assist the States of New Hampshire and Vermont 
with technical and financial aid for the Upper Connecticut River Valley 
through the Connecticut River Joint Commissions. The act would also 
assist local communities with cultural heritage outreach and education 
programs while enriching the recreational activities already active in 
the Connecticut River Watershed of Vermont and New Hampshire.
  Lastly, the bill will require that the Secretary of the Interior 
establish a Connecticut River Grants and Technical Assistance Program 
to help local community groups develop new projects as well as build on 
existing ones to enhance the river basin.
  In the future, I hope this bill will help bring renewed recognition 
and increased efforts to conserve the Connecticut River as one of our 
Nation's great natural and economic resources.
  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 follwos:

                                S. 1117

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Upper Connecticut River 
     Partnership Act''.

     SEC. 2. FINDINGS AND PURPOSE.

       (a) Findings.--Congress finds that--
       (1) the upper Connecticut River watershed in the States of 
     New Hampshire and Vermont is a scenic region of historic 
     villages located in a working landscape of farms, forests, 
     and the mountainous headwaters and broad fertile floodplains 
     of New England's longest river, the Connecticut River;
       (2) the River provides outstanding fish and wildlife 
     habitat, recreation, and hydropower generation for the New 
     England region;
       (3) the upper Connecticut River watershed has been 
     recognized by Congress as part of the Silvio O. Conte 
     National Fish and Wildlife Refuge, established by the Silvio 
     O. Conte National Fish and Wildlife Refuge Act (16 U.S.C. 
     668dd note; Public Law 102-212);
       (4) the demonstrated commitment to stewardship of the River 
     by the citizens living in the watershed led to the 
     Presidential designation of the River as 1 of 14 American 
     Heritage Rivers on July 30, 1998;
       (5) the River is home to the bi-State Connecticut River 
     Scenic Byway, which was declared a National Scenic Byway by 
     the Department of Transportation in 2005 to foster heritage 
     tourism in the region;
       (6) each of the legislatures of the States of Vermont and 
     New Hampshire has established a commission for the 
     Connecticut River watershed, and the 2 commissions, known 
     collectively as the ``Connecticut River Joint Commissions''--
       (A) have worked together since 1989; and
       (B) serve as the focal point and catalyst for cooperation 
     between Federal agencies, States, communities, and citizens;
       (7) in 1997, as directed by the legislatures, the 
     Connecticut River Joint Commissions, with the substantial 
     involvement of 5 bi-State local river subcommittees appointed 
     to represent riverfront towns, produced the 6 volume 
     Connecticut River Corridor Management Plan, to be used as a 
     blueprint in educating agencies, communities, and the public 
     in how to be good neighbors to a great river;
       (8) in 2009, after 3 years of broad consultation, the 
     Connecticut River Joint Commissions have substantially 
     expanded and published updates via the Connecticut River 
     Recreation Management Plan and the Water Resources Management 
     Plan to guide public and private activities in the watershed;
       (9) through a joint legislative resolution, the 
     legislatures of the States of Vermont and New Hampshire have 
     requested that Congress provide for continuation of 
     cooperative partnerships and that Federal agencies support 
     the Connecticut River Joint Commissions in carrying out the 
     recommendations of the Connecticut River Corridor Management 
     Plan;
       (10) this Act effectuates certain recommendations of the 
     Connecticut River Corridor Management Plan that are most 
     appropriately directed by the States through the Connecticut 
     River Joint Commissions, with assistance from the National 
     Park Service and the United States Fish and Wildlife Service; 
     and
       (11) where implementation of those recommendations involves 
     partnership with local communities and organizations, support 
     for the partnership should be provided by the Secretary.
       (b) Purpose.--The purpose of this Act is to authorize the 
     Secretary to provide to the States of New Hampshire and 
     Vermont (including communities in those States), through the 
     Connecticut River Joint Commissions, technical and financial 
     assistance for management of the River.

     SEC. 3. DEFINITIONS.

       In this Act:
       (1) Secretary.--The term ``Secretary'' means the Secretary 
     of the Interior.
       (2) State.--The term ``State'' means--
       (A) the State of New Hampshire; or
       (B) the State of Vermont.

     SEC. 4. CONNECTICUT RIVER GRANTS AND TECHNICAL ASSISTANCE 
                   PROGRAM.

       (a) In General.--The Secretary shall establish a 
     Connecticut River Grants and Technical Assistance Program to 
     provide grants and technical assistance to State and local 
     governments, nonprofit organizations, and the private sector 
     to carry out projects for the conservation, restoration, and 
     interpretation of historic, cultural, recreational, and 
     natural resources in the upper Connecticut River watershed.
       (b) Criteria.--The Secretary, in consultation with the 
     Connecticut River Joint Commissions, shall develop criteria 
     for determining the eligibility of applicants for, and 
     reviewing and prioritizing applications for, grants or 
     technical assistance under the program.
       (c) Cost-Sharing.--
       (1) Federal share.--The Federal share of the cost of 
     carrying out a grant project under subsection (a) shall not 
     exceed 75 percent.
       (2) Non-federal share.--The non-Federal share of the cost 
     of a project may be provided in the form of an in-kind 
     contribution of services or materials.

     SEC. 5. AUTHORIZATION OF APPROPRIATIONS.

       There is authorized to be appropriated to carry out this 
     Act $1,000,000 for each fiscal year.

[[Page S5824]]

                                 ______
                                 
      By Mr. HARKIN:
  S. 1121. A bill to amend part D of title V of the Elementary and 
Secondary Education Act of 1965 to provide grants for the repair, 
renovation, and construction of elementary and secondary schools, 
including early learning facilities at the elementary schools; to the 
Committee on Health, Education, Labor, and Pensions.
  Mr. HARKIN. Mr. President, I rise today to introduce the School 
Building Fairness Act of 2009. I offer this legislation to meet the 
urgent need for Federal support to repair crumbling schools in 
disadvantaged and rural school districts.
  This bill would authorize up to $6 billion annually to fund a new 
program of Federal grants to States for the repair, renovation, and 
construction of public schools. States would award the grants 
competitively, with priority given to high-poverty and rural school 
districts, as well as school districts that plan to make their 
facilities more energy efficient and environmentally friendly. 
Districts receiving this federal funding would then be required to 
provide a local match.
  I know this approach to school construction and repair can work 
because this bill is modeled on the success of the Iowa Demonstration 
and Construction Grant Program in my home State. Over the last decade, 
I have secured $121 million in Federal funds that more than 300 school 
districts across Iowa have used for school construction and repair. 
This modest Federal investment has leveraged more than $600 million in 
additional local funding.
  In addition to improving the learning environment for students, the 
School Building Fairness Act will provide a stimulus to the economy by 
creating jobs in thousands of communities all across the country for 
workers in the construction industry, as well as architects and 
engineers.
  It will also spur school districts to make their facilities more 
environmentally friendly and energy-efficient. According to the 2006 
report ``Greening America's Schools: Costs and Benefits,'' green 
schools use an average of 33 percent less energy than conventionally 
built schools, and generate financial savings of about $70 per square 
foot.
  Safe, modern, healthy school buildings are essential to creating an 
environment where students can reach their academic potential. Yet too 
many students in the U.S., particularly those most at risk of being 
left behind, attend school in facilities that are old, overcrowded and 
run-down.
  We all agree that school infrastructure requires constant 
maintenance. Unfortunately, far too many schools have been forced to 
neglect ongoing issues, most likely due to lack of funds, which can 
lead to health and safety problems for students, educators and staff. 
The most recent Infrastructure Report Card issued by the American 
Society of Civil Engineers gives public schools a D grade. Now, I do 
not know many parents who would find D grades acceptable for their 
children. So why on Earth would we stand by while the state of the 
buildings in which our children learn are assigned such a grade?
  Despite the declining condition of many public schools, federal grant 
funding is generally not available to leverage local spending. In 
fiscal year 2001, in the Senate Labor, Health and Human Services, and 
Education Appropriations Subcommittee, which I then chaired, I was able 
to secure $1.2 billion for school repair and renovation. I continue to 
hear nothing but positive feedback from educators across the country 
about that funding.
  But that one-time investment amounted to nothing more than a drop in 
the bucket compared to the estimated national need. At the beginning of 
this decade, the National Center for Education Statistics estimated 
that the nation's K-12 public schools needed $127 billion in repairs 
and upgrades. A 2008 analysis by the American Federation of Teachers 
found that the Nation's school infrastructure needs total an estimated 
$254.6 billion.
  This bill is called the School Building Fairness Act because, as I 
said, States will give preference in awarding grants to high-poverty 
and rural districts. Currently, spending on school facilities is almost 
twice as high in affluent districts as in disadvantaged districts. This 
is one of those ``savage inequalities'' that Jonathan Kozol writes 
about--inequalities that largely explain the learning gap between 
affluent and poor children.
  Something is seriously wrong when children go to modern, gleaming 
shopping malls and sports arenas, but attend public schools with 
crumbling walls and leaking roofs. This sends exactly the wrong message 
to children about our priorities as adults.
  With the School Building Fairness Act, we have a chance to get our 
priorities right, and to provide a desperately needed boost to school 
districts all across America.
  I hope that my colleagues will join me to help create safe, modern, 
and healthy school environments so all of our children can grow to be 
the leaders of tomorrow.
                                 ______
                                 
      By Mr. BARRASSO (for himself, Mr. Johnson, Mr. Udall of Colorado, 
        Mr. Bennet, Mr. Risch, and Mr. Bennett:
  S. 1122. A bill to authorize the Secretary of Agriculture and the 
Secretary of the Interior to enter into cooperative agreements with 
State foresters authorizing State foresters to provide certain forest, 
rangeland, and watershed restoration and protection services; to the 
Committee on Agriculture, Nutrition, and Forestry.
  Mr. BARRASSO. Mr. President, I am proud to introduce the Good 
Neighbor Forestry Act today along with my Senators Johnson, Udall of 
Colorado, Bennet of Colorado, Risch, and Bennett of Utah. This 
legislation authorizes cooperative action between western states and 
the U.S. Forest Service or Bureau of Land Management to complete forest 
and rangeland health projects on private, State and Federal lands.
  Almost half of the land in Wyoming is managed by Federal agencies. 
Our State has a long history of forestry, grazing and multiple use of 
public lands. Recreation and tourism on our public lands is a pillar of 
our economy. The people of Wyoming are proud stewards of our public 
lands and our state depends on the public lands for our future.
  It is my goal to enact common-sense policies to address the 
management needs of our Federal lands. Wyoming forests, like those of 
all states across the West, are facing management challenges. We have 
an opportunity to meet those challenges with policies that encourage 
forest and rangeland health. Preventing forest fires, removing invasive 
species, addressing watershed health and conserving wildlife habitat 
require ``big picture'' thinking. We have to address these threats at 
the landscape level.
  Resource challenges do not stop at fencelines, and neither should our 
policy.
  The Good Neighbor Forestry Act would set in place a cooperative 
management policy. This act would allow the State of Wyoming to go 
forward with forest and rangeland health projects as agreed to by the 
U.S. Forest Service or Bureau of Land Management. With this authority, 
the agencies can cooperatively pursue projects that address landscape-
level needs. This authority would provide on-the-ground management that 
our private, State, and Federal lands desperately need.
  I am pleased to introduce this legislation today. It is of great 
importance to the people of Wyoming, and public land communities across 
the West. I hope the U.S. Senate will proceed quickly with its passage 
to enhance western states' response to growing management challenges.
  The people of Wyoming demand on-the-ground results. This legislation 
can deliver those results. I hope we can pass it expediently.
  Mr. President, I ask unanimous cnsent 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. 1122

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Good Neighbor Forestry 
     Act''.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Eligible state.--The term ``eligible State'' means a 
     State that contains National Forest System land or Bureau of 
     Land Management land located west of the 100th meridian.

[[Page S5825]]

       (2) Secretary.--The term ``Secretary'' means--
       (A) the Secretary of Agriculture, with respect to National 
     Forest System land; or
       (B) the Secretary of the Interior, with respect to Bureau 
     of Land Management land.
       (3) State forester.--The term ``State forester'' means the 
     head of a State agency with jurisdiction over State forestry 
     programs in an eligible State.

     SEC. 3. COOPERATIVE AGREEMENTS AND CONTRACTS.

       (a) In General.--The Secretary may enter into a cooperative 
     agreement or contract (including a sole source contract) with 
     a State forester to authorize the State forester to provide 
     the forest, rangeland, and watershed restoration and 
     protection services described in subsection (b) on National 
     Forest System land or Bureau of Land Management land, as 
     applicable, in the eligible State.
       (b) Authorized Services.--The forest, rangeland, and 
     watershed restoration and protection services referred to in 
     subsection (a) include the conduct of--
       (1) activities to treat insect infected trees;
       (2) activities to reduce hazardous fuels; and
       (3) any other activities to restore or improve forest, 
     rangeland, and watershed health, including fish and wildlife 
     habitat.
       (c) State as Agent.--Except as provided in subsection (f), 
     a cooperative agreement or contract entered into under 
     subsection (a) may authorize the State forester to serve as 
     the agent for the Secretary in providing the restoration and 
     protection services authorized under subsection (a).
       (d) Subcontracts.--In accordance with applicable contract 
     procedures for the eligible State, a State forester may enter 
     into subcontracts to provide the restoration and protection 
     services authorized under a cooperative agreement or contract 
     entered into under subsection (a).
       (e) Timber Sales.--Subsections (d) and (g) of section 14 of 
     the National Forest Management Act of 1976 (16 U.S.C. 472a) 
     shall not apply to services performed under a cooperative 
     agreement or contract entered into under subsection (a).
       (f) Retention of NEPA Responsibilities.--Any decision 
     required to be made under the National Environmental Policy 
     Act of 1969 (42 U.S.C. 4321 et seq.) with respect to any 
     restoration and protection services to be provided under this 
     Act by a State forester on National Forest System land or 
     Bureau of Land Management land, as applicable, shall not be 
     delegated to a State forester or any other officer or 
     employee of the eligible State.
       (g) Applicable Law.--The restoration and protection 
     services to be provided under this Act shall be carried out 
     on a project-to-project basis under existing authorities of 
     the Forest Service or Bureau of Land Management, as 
     applicable.

     SEC. 4. TERMINATION OF EFFECTIVENESS.

       (a) In General.--The authority of the Secretary to enter 
     into cooperative agreements and contracts under this Act 
     terminates on September 30, 2018.
       (b) Contract Date.--The termination date of a cooperative 
     agreement or contract entered into under this Act shall not 
     extend beyond September 30, 2019.
                                 ______
                                 
      By Ms. COLLINS (for herself, Mrs. Lincoln, and Mr. Bond):
  S. 1123. A bill to provide for a five-year payment increase under the 
Medicare program for home health services furnished in a rural area; to 
the Committee on Finance.
  Ms. COLLINS. Mr. President, I rise today with my colleagues from 
Arkansas and Missouri to introduce the Medicare Rural Home Health 
Payment Fairness Act to reinstate the 5 percent add-on payment for home 
health services in rural areas that expired on January 1, 2007.
  Home health has become an increasingly important part of our health 
care system. The kinds of highly skilled--and often technically 
complex--services that our Nation's home health caregivers provide have 
enabled millions of our most frail and vulnerable older and disabled 
citizens to avoid hospitals and nursing homes and stay just where they 
want to be--in the comfort and security of their own homes. I have 
accompanied several of Maine's caring home health nurses on their 
visits to some of their patients. I have seen first hand the difference 
that they are making for Maine's elderly.
  Surveys have shown that the delivery of home health services in rural 
areas can be as much as 12 to 15 percent more costly because of the 
extra travel time required to cover long distances between patients, 
higher transportation expenses, and other factors. Because of the 
longer travel times, rural caregivers are unable to make as many visits 
in a day as their urban counterparts. The executive director of the 
Visiting Nurses of Aroostook in Northern Maine, where I am from, tells 
me her agency covers 6,600 square miles with a total population of only 
73,000. This agency's costs are understandably much higher than other 
agencies due to the long distances the staff must drive to see clients. 
Moreover, the staff is not able to see as many patients due to time on 
the road.
  Agencies in rural areas are also frequently smaller than their urban 
counterparts, which means that their relative costs are higher. Smaller 
agencies with fewer patients and fewer visits mean that fixed costs, 
particularly those associated with meeting regulatory requirements, are 
spread over a much smaller number of patients and visits, increasing 
overall per-patient and per-visit costs.

  Moreover, in many rural areas, home health agencies are the primary 
caregivers for homebound beneficiaries with limited access to 
transportation. These rural patients often require more time and care 
than their urban counterparts, and are understandably more expensive 
for agencies to serve. If the extra rural payment is not extended, 
agencies may be forced to make decisions not to accept rural patients 
with greater care needs. That could translate into less access to 
health care for ill, homebound seniors. The result would likely be that 
these seniors would be hospitalized more frequently and would have to 
seek care in nursing homes, adding considerable cost to the system.
  Failure to extend the rural add-on payment will only put more 
pressure on rural home health agencies that are already operating on 
very narrow margins and could force some of the agencies to close their 
doors altogether. Many home health agencies operating in rural areas 
are the only home health providers in large geographic areas. If any of 
these agencies were forced to close, the Medicare patients in that 
region could lose all of their access to home care.
  The legislation we are introducing today will extend the rural add-on 
for 5 years and help to ensure that Medicare patients in rural areas 
continue to have access to the home health services they need. I urge 
all of our colleagues to join us as cosponsors.
                                 ______
                                 
      By Mr. DURBIN:
  S. 1125. A bill to amend the National Voter Registration Act of 1993 
to provide for the treatment of institutions of higher education as 
voter registration agencies; to the Committee on Rules and 
Administration.
  Mr. DURBIN. 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. 1125

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Student Voter Opportunity To 
     Encourage Registration Act of 2009'' or the ``Student VOTER 
     Act of 2009''.

     SEC. 2. TREATMENT OF UNIVERSITIES AS VOTER REGISTRATION 
                   AGENCIES.

       (a) In General.--Section 7(a) of the National Voter 
     Registration Act of 1993 (42 U.S.C. 1973gg-5(a)) is amended--
       (1) in paragraph (2)--
       (A) by striking ``and'' at the end of subparagraph (A);
       (B) by striking the period at the end of subparagraph (B) 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(C) each institution of higher education (as defined in 
     section 101 of the Higher Education Act of 1965 (20 U.S.C. 
     1001)) in the State that receives Federal funds.''; and
       (2) in paragraph (6)(A), by inserting ``or, in the case of 
     an institution of higher education, with each registration of 
     a student for enrollment in a course of study'' after 
     ``assistance,''.
       (b) Amendment to Higher Education Act of 1965.--Section 
     487(a) of the Higher Education Act of 1965 (20 U.S.C. 
     1094(a)) is amended by striking paragraph (23).
                                 ______
                                 
      By Mr. REID:
  S. 1126. A bill to require the Director of National Intelligence to 
submit a report to Congress on retirement benefits for former employees 
of Air America and for other purposes; to the Select Committee on 
Intelligence.
  Mr. REID. Mr. President, it has been said that ``The nation which 
forgets its defenders will itself be forgotten.'' I believe it. This is 
why I rise today to again introduce legislation to help correct an 
injustice for those who have served our country in times of crisis.
  Many people have never heard of Air America. This top-secret 
passenger and cargo airline was a Government corporation owned and 
operated by the

[[Page S5826]]

Central Intelligence Agency during the Cold War.
  Forty-eight years ago, the first Air America pilots were killed in 
covert military action in Laos. On May 30th, 1961, Charles Mateer and 
Walter Wizbowski crashed their helicopter in rugged terrain and 
unpredictable weather while trying to land in order to resupply 
besieged Hmong during the Cold War.
  Air America employed several hundred U.S. citizens like Mr. Mateer 
and Wizbowski to conduct covert missions throughout the Cold War. 
During the Vietnam War, they carried nearly 12,000 government-sponsored 
passengers each month including troops and refugees. During the final 
days of the Vietnam war, Air America helicopters evacuated some 41,000 
Americans, diplomats and friendly Vietnamese. Throughout the Cold War, 
numerous Air Force and Navy pilots were saved by heroic Air America 
helicopter rescue missions after being shot down behind enemy lines.
  Air America personnel paid a costly burden to run these dangerous 
missions. Sadly, at least 86 American pilots were killed in action 
while operating aircraft for our Government. In all, Air America had 
240 pilots and crewmembers killed in action.
  In order to be able to conduct these high-risk missions, Air America 
operations were conducted by the CIA with strict secrecy. The 
Government ownership of the company was never acknowledged at the time 
and was not known to the public. Only a small number of officials were 
aware that, as employees of the CIA, Air America personnel were 
entitled to standard benefits provided to Federal employees.
  Despite their heroic service to our nation, Air America employees are 
now being neglected by our Government.
  Frustrated by Federal intransience and bureaucracy, former Air 
America employees from Nevada came to me and requested congressional 
assistance to help them obtain Federal civil service retirement 
benefits.
  Today, the legislation I am introducing helps move us closer to 
correcting this injustice.
  Mr. President, the ``Air America Veteran's Act'' recognizes these 
employees by requiring the Director of National Intelligence to submit 
a report to Congress about the number of Air America beneficiaries and 
the benefits owed to them. This report is critical because it will 
provide the justification Congress needs to ensure that these veterans 
are treated equitably and fairly by their Government.
  I encourage all of my colleagues to join me in cosponsoring this 
important legislation to correct this injustice. These great Americans 
have earned these benefits and the gratitude of a thankful Nation. Now 
is our chance to honor their service and begin recognizing their 
sacrifices.
  Mr. Presdient, I ask unanimous consent that the text of the bill be 
printed in Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1126

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Air America Veterans Act of 
     2009''.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Air america.--The term ``Air America'' means Air 
     America, Incorporated.
       (2) Associated company.--The term ``associated company'' 
     means any entity associated with, predecessor to, or 
     subsidiary to Air America, including Air Asia Company 
     Limited, CAT Incorporated, Civil Air Transport Company 
     Limited, and the Pacific Division of Southern Air Transport 
     during the period when such an entity was owned and 
     controlled by the United States Government.

     SEC. 3. REPORT ON RETIREMENT BENEFITS FOR FORMER EMPLOYEES OF 
                   AIR AMERICA.

       (a) In General.--Not later than 180 days after the date of 
     the enactment of this Act, the Director of National 
     Intelligence shall submit to Congress a report on the 
     advisability of providing Federal retirement benefits to 
     United States citizens for the service of such citizens prior 
     to 1977 as employees of Air America or an associated company 
     during a period when Air America or the associated company 
     was owned or controlled by the United States Government and 
     operated or managed by the Central Intelligence Agency.
       (b) Report Elements.--The report required by subsection (a) 
     shall include the following:
       (1) The history of Air America and the associated companies 
     prior to 1977, including a description of--
       (A) the relationship between Air American and the 
     associated companies and the Central Intelligence Agency or 
     any other element of the United States Government;
       (B) the workforce of Air America and the associated 
     companies;
       (C) the missions performed by Air America, the associated 
     companies, and their employees for the United States; and
       (D) the casualties suffered by employees of Air America and 
     the associated companies in the course of their employment.
       (2) A description of--
       (A) the retirement benefits contracted for or promised to 
     the employees of Air America and the associated companies 
     prior to 1977;
       (B) the contributions made by such employees for such 
     benefits;
       (C) the retirement benefits actually paid such employees;
       (D) the entitlement of such employees to the payment of 
     future retirement benefits; and
       (E) the likelihood that such employees will receive any 
     future retirement benefits.
       (3) An assessment of the difference between--
       (A) the retirement benefits that former employees of Air 
     America and the associated companies have received or will 
     receive by virtue of their employment with Air America and 
     the associated companies; and
       (B) the retirement benefits that such employees would have 
     received or be eligible to receive if such employment was 
     deemed to be employment by the United States Government and 
     their service during such employment was credited as Federal 
     service for the purpose of Federal retirement benefits.
       (4)(A) Any recommendations regarding the advisability of 
     legislative action to treat such employment as Federal 
     service for the purpose of Federal retirement benefits in 
     light of the relationship between Air America and the 
     associated companies and the United States Government and the 
     services and sacrifices of such employees to and for the 
     United States.
       (B) If legislative action is considered advisable under 
     subparagraph (A), a proposal for such action and an 
     assessment of its costs.
       (5) The opinions of the Director of the Central 
     Intelligence Agency, if any, on any matters covered by the 
     report that the Director of the Central Intelligence Agency 
     considers appropriate.
       (c) Assistance of Comptroller General.--The Comptroller 
     General of the United States shall, upon the request of the 
     Director of National Intelligence and in a manner consistent 
     with the protection of classified information, assist the 
     Director in the preparation of the report required by 
     subsection (a).
       (d) Form.--The report required by subsection (a) shall be 
     submitted in unclassified form, but may include a classified 
     annex.
                                 ______
                                 
      By Mr. DURBIN (for himself and Mr. Burr):
  S. 1129. A bill to authorize the Secretary of Education to award 
grants to local educational agencies to improve college enrollment; to 
the Committee on Health, Education, Labor, and Pensions.
  Mr. DURBIN. Mr. President, an educated workforce is crucial to the 
success of the American economy. A recent report from the consulting 
firm McKinsey, ``The Economic Impact of the Achievement Gap in 
America's Schools,'' concludes that if America had raised the 
educational attainment of our students to those of high-performing 
nations like Finland and South Korea between 1983 and 1998, U.S. G.D.P. 
in 2008 would have been between $1.3 trillion and $2.3 trillion higher 
than it is today. If the gap between low-income American students and 
American students of higher means had been narrowed, G.D.P. in 2008 
would have been $400 billion to $670 billion higher.
  If we want to be economically competitive and avoid future 
recessions, we need to close the achievement gap in education for all 
Americans. In his first speech to Congress, President Obama set a goal 
of having the highest college graduation rate in the world by 2020. Too 
many students are not receiving a college education, and we will have 
to do far better to reach the President's goal.
  Of students who were in eighth grade in 2000, only 20 percent of the 
lowest-income students will earn a college degree by 2012, compared to 
68 percent of the highest income group. Every student who wants to go 
to college should have that opportunity, and we should provide them 
with the tools they need.
  Today, I am introducing the Pathways to College Act with Senator 
Burr, which creates grants for school districts to help them increase 
the number of low-income students who are entering and succeeding in 
college.
  Lack of guidance and information about college has a real effect on 
students in poor schools. The Consortium

[[Page S5827]]

on Chicago School Research released a report last year, ``Potholes on 
the Road to College,'' that looks at the difficulties Chicago Public 
School students face during the college application process. The 
Consortium discovered that only 41 percent of Chicago Public School 
students who wanted to go to college took the steps necessary to apply 
to and enroll in a 4-year college. Only one-third of students enrolled 
in a college that matched their qualifications. Of the students who had 
the grades and test scores to attend a selective college, 29 percent 
went to a community college or skipped college entirely.
  The Pathways to College Act would create a grant program for school 
districts serving low-income students to increase their college-
enrollment rates. The Consortium's ``Potholes'' report found that the 
most important factor in whether students enroll in a four-year college 
is if they attended a school where teachers create a strong college-
going culture and help students with the process of applying. The 
Pathways to College Act would provide the funding to help school 
districts improve the college-going culture in schools and guide 
students through the college admissions process.
  The Pathways to College Act provides flexibility to school districts 
to achieve higher college enrollment rates, but requires that each 
school accurately track their results so we can learn from what works. 
Chicago Public Schools is doing a great job--both in tackling the 
problem and in documenting progress. Under the leadership of Arne 
Duncan, Chicago Public Schools responded aggressively to the 
``Potholes'' report.
  A team of postsecondary coaches were deployed in high schools to work 
with students and counselors. To ensure that financial aid is not a 
roadblock, FAFSA completion rates are tracked so that counselors can 
follow-up with students. A spring-break college tour took 500 students 
to see colleges across the country. Because Chicago Public Schools 
tracks its college enrollment rates, we know that their efforts are 
working.
  Half of the 2007 graduating class enrolled in college, an increase of 
6.5 percent in 4 years. The national increase was less than 1 percent 
in the same time-frame. Nationally, the number of African-American 
graduates going to college has decreased by 6 percent over the last 4 
years while the Chicago rate has increased by almost 8 percent.
  Applying to college is not easy. Low-income students often need the 
most help to achieve their college dreams. When schools focus on 
college and provide the tools to get there, students make the 
connection between the work they are doing now and their future goals 
in college and life. Students in those schools are more likely enroll 
in college and are also more likely to work hard in high school to be 
prepared for college when they arrive. The bill we are introducing 
today tries to ensure that lack of information never prevents a student 
from achieving his or her college dream.
  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. 1129

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Pathways to College Act''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) An educated workforce is crucial to the success of the 
     United States economy. Access to higher education for all 
     students is critical to maintaining an educated workforce. 
     More than 80 percent of the 23,000,000 jobs that will be 
     created in the next 10 years will require postsecondary 
     education. Only 36 percent of all 18- to 24-year olds are 
     currently enrolled in postsecondary education.
       (2) Workers with bachelor's degrees earn on average $17,000 
     more annually than workers with only high school diplomas. 
     Workers who earn bachelor's degrees can be expected to earn 
     $1,000,000 more over a lifetime than those who only finished 
     high school.
       (3) In order to prepare students for college, all schools 
     should--
       (A) provide student guidance to engage students in college 
     and career awareness; and
       (B) ensure that students enroll in a rigorous curriculum to 
     prepare for postsecondary education.
       (4) The Department of Education reports that the average 
     student-to-counselor ratio in high schools is 315:1. This is 
     far higher than the ratio recommended by the American School 
     Counselor Association, which is 250:1. While school 
     counselors at private schools spend an average of 58 percent 
     of their time on postsecondary education counseling, school 
     counselors in public schools spend an average of 25 percent 
     of their time on postsecondary education counseling.
       (5) While just 57 percent of students from the lowest 
     income quartile enroll in college, 87 percent of students 
     from the top income quartile enroll. Of students who were in 
     eighth grade in 2000, only 20 percent of the lowest-income 
     students are projected to attain a bachelor's degree by 2012, 
     compared to 68 percent of the highest income group, according 
     to the Advisory Committee on Student Financial Assistance in 
     2006.
       (6) A recent report by the Consortium on Chicago School 
     Research found that only 41 percent of Chicago public school 
     students who aspire to go to college took the steps necessary 
     to apply to and enroll in a 4-year institution of higher 
     education. The report also reveals that only \1/3\ of Chicago 
     students who want to attend a 4-year institution of higher 
     education enroll in a school that matches their 
     qualifications. Even among students qualified to attend a 
     selective college, 29 percent enrolled in a community college 
     or did not enroll at all.
       (7) The Consortium found that many Chicago public school 
     students do not complete the Free Application for Federal 
     Student Aid, even though students who apply for Federal 
     financial aid are 50 percent more likely to enroll in 
     college. Sixty-five percent of public secondary school 
     counselors at low-income schools believe that students and 
     parents are discouraged from considering college as an option 
     due to lack of knowledge about financial aid.
       (8) Low-income and first-generation families often 
     overestimate the cost of tuition and underestimate available 
     aid; students from these backgrounds have access to fewer 
     college application resources and financial aid resources 
     than other groups, and are less likely to fulfill their 
     postsecondary plans as a result.
       (9) College preparation intervention programs can double 
     the college-going rates for at-risk youth, can expand 
     students' educational aspirations, and can boost college 
     enrollment and graduation rates.

     SEC. 3. GRANT PROGRAM.

       (a) Definitions.--In this Act:
       (1) College-going rate.--The term ``college-going rate'' 
     means the percentage of high school graduates who enroll at 
     an institution of higher education in the school year 
     immediately following graduation from high school.
       (2) Eligible local educational agency.--The term ``eligible 
     local educational agency'' means a local educational agency 
     in which a majority of the high schools served by the agency 
     are high-need high schools.
       (3) High-need high school.--The term ``high-need high 
     school'' means a high school in which not less than 50 
     percent of the students enrolled in the school are--
       (A) eligible to receive a free or reduced price lunch under 
     the Richard B. Russell National School Lunch Act (42 U.S.C. 
     1751 et seq.);
       (B) eligible to be counted under section 1124(c) of the 
     Elementary and Secondary Education Act of 1965 (20 U.S.C. 
     6333(c)); or
       (C) in families eligible for assistance under the State 
     program funded under part A of title IV of the Social 
     Security Act (42 U.S.C. 601 et seq.).
       (4) High school.--The term ``high school'' means a 
     nonprofit institutional day or residential school, including 
     a public charter high school, that provides high school 
     education, as determined under State law.
       (5) High school graduation rate.--The term ``high school 
     graduation rate''--
       (A) means the percentage of students who graduate from high 
     school with a regular diploma in the standard number of 
     years; and
       (B) is clarified in section 200.19(b)(1) of title 34, Code 
     of Federal Regulations.
       (6) Institution of higher education.--The term 
     ``institution of higher education'' has the meaning given the 
     term in section 101(a) of the Higher Education Act of 1965 
     (20 U.S.C. 1001(a)).
       (7) Local educational agency.--The term ``local educational 
     agency'' has the meaning given the term in section 9101 of 
     the Elementary and Secondary Education Act of 1965 (20 U.S.C. 
     7801).
       (8) Parent.--The term ``parent'' has the meaning given the 
     term in section 9101 of the Elementary and Secondary 
     Education Act of 1965 (20 U.S.C. 7801).
       (9) Secretary.--The term ``Secretary'' means the Secretary 
     of Education.
       (b) Competitive Grants to Eligible Local Educational 
     Agencies.--The Secretary is authorized to award grants, on a 
     competitive basis, to eligible local educational agencies to 
     carry out the activities described in this section.
       (c) Duration.--Grants awarded under this section shall be 5 
     years in duration.
       (d) Distribution.--In awarding grants under this section, 
     the Secretary shall ensure that the grants are distributed 
     among the different geographic regions of the United States, 
     and among eligible local educational agencies serving urban 
     and rural areas.
       (e) Applications.--
       (1) In general.--Each eligible local educational agency 
     desiring a grant under this

[[Page S5828]]

     section shall submit an application to the Secretary at such 
     time, in such manner, and accompanied by such information as 
     the Secretary may reasonably require.
       (2) Contents.--Each application submitted under paragraph 
     (1) shall include a description of the program to be carried 
     out with grant funds and--
       (A) a detailed description of the high school population to 
     be targeted by the program, the particular college-access 
     needs of such population, and the resources available for 
     meeting such needs;
       (B) measurable objectives of the program, including goals 
     for increasing the number of college applications submitted 
     by each student and the number of students submitting 
     applications, increasing Free Application for Federal Student 
     Aid completion rates, and increasing school-wide college-
     going rates across the local educational agency;
       (C) a description of the local educational agency's plan to 
     work cooperatively, where applicable, with programs funded 
     under chapters 1 and 2 of subpart 2 of part A of title IV of 
     the Higher Education Act of 1965 (20 U.S.C. 1070a-11 et seq. 
     and 1070a-21 et seq.), including the extent to which the 
     agency commits to sharing facilities, providing access to 
     students, and developing compatible record-keeping systems;
       (D) a description of the activities, services, and training 
     to be provided by the program, including a plan to provide 
     structure and support for all students in the college search, 
     planning, and application process;
       (E) a description of the methods to be used to evaluate the 
     outcomes and effectiveness of the program;
       (F) an assurance that grant funds will be used to 
     supplement, and not supplant, any other Federal, State, or 
     local funds available to carry out activities of the type 
     carried out under the grant;
       (G) an explanation of the method used for calculating 
     college enrollment rates for each high school served by the 
     eligible local educational agency that is based on externally 
     verified data, and, when possible, aligned with existing 
     State or local methods;
       (H) a plan to make the program sustainable over time, 
     including the use of matching funds from non-Federal sources; 
     and
       (I) a description of the local educational agency's plan to 
     work cooperatively, where applicable, with the program funded 
     under part H of title VIII of the Higher Education Act of 
     1965 (20 U.S.C. 1161h et seq.), including the extent to which 
     the agency commits to using and leveraging--
       (i) the needs assessment and recommendations;
       (ii) the model for measuring college enrollment; and
       (iii) comprehensive services.
       (3) Method of calculating enrollment rates.--
       (A) In general.--A method included in an application under 
     paragraph (2)(G)--
       (i) shall, at a minimum, track students' first-time 
     enrollment in institutions of higher education; and
       (ii) may track progress toward completion of a 
     postsecondary degree.
       (B) Development in conjunction.--An eligible local 
     educational agency may develop a method pursuant to paragraph 
     (2)(G) in conjunction with an existing public or private 
     entity that currently maintains such a method.
       (f) Special Consideration.--In awarding grants under this 
     section, the Secretary shall give special consideration to 
     applications from eligible local educational agencies serving 
     schools with the highest percentages of poverty.
       (g) Use of Funds.--
       (1) In general.--An eligible local educational agency that 
     receives a grant under this section shall develop and 
     implement, or expand, a program to increase the number of 
     low-income students who enroll in postsecondary educational 
     institutions, including institutions with competitive 
     admissions criteria.
       (2) Required use of funds.--Each program funded under this 
     section shall--
       (A) provide professional development to high school 
     teachers and school counselors in postsecondary education 
     advising;
       (B) implement a comprehensive college guidance program for 
     all students in a high school served by an eligible local 
     educational agency under this section that--
       (i) ensures that all students and their parents, are 
     regularly notified throughout the students' time in high 
     school, beginning in the first year of high school, of--

       (I) high school graduation requirements;
       (II) college entrance requirements;
       (III) the economic and social benefits of higher education;
       (IV) college expenses, including information about expenses 
     by institutional type, differences between sticker price and 
     net price, and expenses beyond tuition; and
       (V) the resources for paying for college, including the 
     availability, eligibility, and variety of financial aid;

       (ii) provides assistance to students in registering for and 
     preparing for college entrance tests;
       (iii) provides one-on-one guidance and assistance to 
     students in applying to an institution of higher education 
     and in applying for Federal financial aid assistance and 
     other State, local, and private financial aid assistance and 
     scholarships;
       (iv) provides opportunities for students to explore 
     postsecondary opportunities outside of the school setting, 
     such as college fairs, career fairs, college tours, workplace 
     visits, or other similar activities; and
       (v) provides not less than 1 meeting for each student, not 
     later than the first semester of the first year of high 
     school, with a school counselor, college access personnel 
     (including personnel involved in programs funded under 
     chapters 1 and 2 of subpart 2 of part A of title IV of the 
     Higher Education Act of 1965 (20 U.S.C. 1070a-11 et seq. and 
     1070a-21 et seq.)), trained teacher, or other professional or 
     organization, such as a community-based organization, 
     approved by the school, to discuss postsecondary options, 
     outline postsecondary goals, and create a plan to achieve 
     those goals, and provides not less than 2 meetings in each 
     year to discuss progress on the plan;
       (C) ensure that each high school served by the eligible 
     local educational agency develops a comprehensive, school-
     wide plan of action to strengthen the college-going culture 
     within the high school; and
       (D) create or maintain a postsecondary access center in the 
     school setting that provides information on colleges and 
     universities, career opportunities, and financial aid options 
     and provide a setting in which professionals working in 
     college access programs, such as those funded under chapters 
     1 and 2 of subpart 2 of part A of title IV of the Higher 
     Education Act of 1965 (20 U.S.C. 1070a-11 et seq. and 1070a-
     21 et seq.), can meet with students.
       (3) Allowable use of funds.--Each program funded under this 
     section may--
       (A) establish mandatory postsecondary planning classes for 
     high school students to assist in the college preparation and 
     application process;
       (B) hire and train postsecondary coaches with expertise in 
     the college-going process to supplement existing school 
     counselors;
       (C) increase the number of school counselors who specialize 
     in the college-going process serving students;
       (D) train student leaders to assist in the creation of a 
     college-going culture in their schools;
       (E) establish partnerships with programs funded under 
     chapters 1 and 2 of subpart 2 of part A of title IV of the 
     Higher Education Act of 1965 (20 U.S.C. 1070a-11 et seq. and 
     1070a-21 et seq.)), and with community and nonprofit 
     organizations to increase college-going rates at high schools 
     served by the eligible local educational agency;
       (F) provide long-term postsecondary follow up with 
     graduates of the high schools served by the eligible local 
     educational agencies, including increasing alumni involvement 
     in mentoring and advising roles within the high school; and
       (G) deliver college and career planning curriculum as a 
     stand-alone course, or embedded in other classes, or 
     delivered through the guidance curriculum by the school 
     counselor for all students in high school.
       (h) Supplement, Not Supplant.--Funds made available under 
     this section shall be used to supplement, and not supplant, 
     other Federal, State, and local funds available to carry out 
     the activities described in this section.
       (i) Technical Assistance.--The Secretary, directly or 
     through contracting through a full and open process with 1 or 
     more organizations that have demonstrated experience 
     providing technical assistance to raise school-wide college-
     going rates in local educational agencies in not less than 3 
     States, shall provide technical assistance to grantees in 
     carrying out this section. The technical assistance shall--
       (1) provide assistance in the calculation and analysis of 
     college-going rates for all grant recipients;
       (2) provide semi-annual analysis to each grant recipient 
     recommending best practices based on a comparison of the 
     recipient's data with that of high schools with similar 
     demographics; and
       (3) provide annual best practices conferences for all grant 
     recipients.
       (j) Reporting Requirements.--Each eligible local 
     educational agency receiving a grant under this section shall 
     collect and report annually to the Secretary such information 
     for the local educational agency and for each high school 
     assisted under this section on the results of the activities 
     assisted under the grant as the Secretary may reasonably 
     require, including information on--
       (1) the number and percentage of students who enroll in an 
     institution of higher education in the school year 
     immediately following the students' high school graduation as 
     measured by externally verified school-wide college 
     enrollment data;
       (2) the number and percentage of students who graduate from 
     high school on time with a regular high school diploma;
       (3) the number and percentage of students, at each grade 
     level, who are on track to graduate from high school on time 
     and with a regular high school diploma;
       (4) the number and percentage of senior high school 
     students who apply to an institution of higher education and 
     the average number of applications completed and submitted by 
     students;
       (5) the number and percentage of senior high school 
     students who file the Free Application for Federal Student 
     Aid forms;
       (6) the number and percentage of students, in grade 10, who 
     take early admissions assessments, such as the PSAT;
       (7) the number and percentage of students, in grades 11 and 
     12, who take the SAT or ACT, and the students' mean scores on 
     such assessments;

[[Page S5829]]

       (8) where data are available, the number and percentage of 
     students enrolled in remedial mathematics or English courses 
     during their freshman year at an institution of higher 
     education;
       (9) the number and percentage of students, in grades 11 and 
     12, enrolled in not less than 2 of the following:
       (A) a dual credit course; or
       (B) an Advanced Placement or International Baccalaureate 
     course; and
       (10) the number and percentage of students who meet or 
     exceed State reading or language arts, mathematics, or 
     science standards, as measured by State academic assessments 
     required under section 1111(b)(3) of the Elementary and 
     Secondary Education Act of 1965 (20 U.S.C. 6311(b)(3)).
       (k) Reporting of Data.--Each eligible local educational 
     agency receiving a grant under this section shall report to 
     the Secretary, where possible, the information required under 
     subsection (j) disaggregated in the same manner as 
     information is disaggregated under section 1111(h)(1)(C)(i) 
     of the Elementary and Secondary Education Act of 1965 (20 
     U.S.C. 6311(h)(1)(C)(i)).
       (l) Evaluations by Grantees.--Each eligible local 
     educational agency that receives a grant under this section 
     shall--
       (1) conduct periodic evaluations of the effectiveness of 
     the activities carried out under the grant toward increasing 
     school-wide college-going rates;
       (2) use such evaluations to refine and improve activities 
     conducted with the grant and the performance measures for 
     such activities; and
       (3) make the results of such evaluations publicly 
     available, including by providing public notice of such 
     availability.
       (m) Report.--From the amount appropriated for any fiscal 
     year, the Secretary shall reserve such sums as may be 
     necessary--
       (1) to conduct an independent evaluation, by grant or by 
     contract, of the programs carried out under this section, 
     which shall include an assessment of the impact of the 
     program on high school graduation rates and college-going 
     rates; and
       (2) to prepare and submit a report on the results of the 
     evaluation described in paragraph (1) to the Committee on 
     Health, Education, Labor, and Pensions of the Senate and the 
     Committee on Education and Labor of the House of 
     Representatives.
       (n) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section such sums as may 
     be necessary for fiscal year 2010 and each of the 5 
     succeeding fiscal years.
                                 ______
                                 
      By Ms. SNOWE (for herself, Mr. Conrad, Mr. Wyden, and Ms. 
        Collins):
  S. 1130. A bill to provide for a demonstration project regarding 
Medicaid reimbursements for stabilization of emergency medical 
conditions by non-publicly owned or operated institutions for mental 
diseases; to the Committee on Finance.
  Ms. SNOWE. Mr. President, today, I rise to introduce the Medicaid 
Emergency Psychiatric Care Demonstration Project Act. I am pleased to 
be joined by Senators Conrad, Wyden and Collins in this effort. We are 
introducing this legislation to address an unfair conflict in two 
Federal laws--the Institution for Mental Diseases, IMD, Exclusion and 
The Emergency Medical and Labor Treatment Act, EMTALA.
  EMTALA requires all hospitals, including freestanding psychiatric 
hospitals, to stabilize patients who come in with an emergency medical 
condition. At the same time, under an outdated Medicaid provision 
called the IMD exclusion, adult Medicaid patients, 21-64, are not 
covered for inpatient psychiatric care in a freestanding psychiatric 
hospital, but are covered in a general hospital psychiatric unit. Yet 
both types of hospitals are required to stabilize any patient--which 
may require hospitalization--who comes to them for emergency care 
regardless of ability to pay.
  In order to correct this inequity, we have introduced the Medicaid 
Emergency Psychiatric Care Demonstration Project Act. This legislation 
would establish a 3-year, demonstration program capped at $75 million, 
which would allow states to apply for federal Medicaid matching funds 
to demonstrate that covering Medicaid patients in freestanding, non-
governmental psychiatric hospitals will improve timely access to 
emergency psychiatric care, reduce the burden on overcrowded emergency 
rooms, and improve the efficiency and cost-effectiveness of inpatient 
psychiatric care. Our legislation helps alleviate a problem where 
patients with significant mental health needs are often forced to 
endure prolonged stays in emergency rooms and hospitals without the 
psychiatric attention they require.
  The measure is supported by 27 national healthcare organizations, 
including the National Alliance for the Mentally Ill--the country's 
largest advocacy organization for the mentally ill, the National 
Association of Psychiatric Health Systems, the American Hospital 
Association, the Federation of American Hospitals, the American 
Psychiatric Association, the National Association of County Behavioral 
Healthcare Directors, the American College of Emergency Physicians, and 
the Emergency Nurses Association.
                                 ______
                                 
      By Mr. WYDEN (for himself, Mr. Burr, Mr. Whitehouse, and Mr. 
        Cardin):
  S. 1131. A bill to amend title XVIII of the Social Security Act to 
provide certain high cost Medicare beneficiaries suffering from 
multiple chronic conditions with access to coordinated, primary care 
medical services in lower cost treatment settings, such as their 
residences, under a plan of care developed by a team of qualified and 
experienced health care professionals; to the Committee on Finance.
  Mr. WYDEN. Mr. President, I am reintroducing the Independence at Home 
Act together with colleagues in the Senate and the House. Mr. Burr, Mr. 
Whitehouse, Mr. Cardin and I are proud to join forces with our House 
colleagues, Mr. Markey, and his cosponsor, Mr. Smith, to move forward 
with this important legislation to provide a coordinated team-based 
approach to primary care for chronically ill Medicare beneficiaries in 
their own homes. Returning to basics like paying doctors for home 
visits to vulnerable patients, and following them through the course of 
their illness while saving taxpayers money, is the kind of legislation 
I am proud to introduce.
  The Independence at Home, or IAH, Act comes at the perfect time. The 
American people and the federal government need to save money on health 
care, while having more choices and getting better results. This 
delivery model has a proven track record of doing just this. Similar 
``house calls'' programs, currently operating across the country, are 
reducing costs, improving care quality, and helping people remain 
independent as long as possible. This delivery model is also providing 
much needed relief to caregivers who are often juggling a full-time job 
while caring for their very ill family member. This is medical care 
Americans want and deserve.
  It is not too often that health policy has good outcome results 
before the pilot program phase begins, but that is exactly the case 
with the IAH Act. Similar home health delivery models, such as the 
Veterans Administration's Home-Based Primary Care, Boston, 
Massachusetts' Urban Medical's House Calls Program, and Portland, 
Oregon's Housecall Providers have been so successful in improving 
quality and reducing costs, that our bill guarantees 5 percent savings 
to Medicare.
  These successful home health programs have demonstrated that the 
optimal way to address the challenges of caring for persons with 
chronic conditions is to better integrate their care and to work with 
their caregivers. Medical problems are best managed and coordinated by 
health care professionals who know their patients, their problems, 
their medications, and their other health care providers. Using this 
approach, the Independence at Home Act provides a better, more cost-
effective way for Medicare patients with chronic conditions to get the 
care they need. It further advances Medicare reform by creating 
incentives for providers to develop better and lower cost health care 
for the highest cost beneficiaries.
  This bipartisan, bicameral bill would create a pilot program to 
improve in-home care availability for beneficiaries with multiple 
chronic conditions. This is a win-win for all involved. It will help 
people remain in their homes for longer periods of time, it will 
improve the quality of care, and physicians will receive a bundled 
payment for coordinating this care with a team of healthcare providers.
  More specifically, the Independence at Home Act establishes a two-
phase three-year Medicare pilot project that uses a patient-centered 
health care delivery model to ensure that Medicare beneficiaries with 
multiple chronic conditions can remain independent for as long as 
possible in a comfortable environment. By incorporating lessons from 
past Medicare demonstration projects and from current home health

[[Page S5830]]

models, this bill provides for programs that hold providers accountable 
for quality, mandatory annual minimum savings, and patient 
satisfaction. Savings are generated by providing better care to 
Medicare beneficiaries with multiple chronic conditions and reducing 
duplicative and unnecessary services, hospitalization, and other health 
care costs.
  Persons eligible for the program include Medicare beneficiaries with 
functional impairments, two or more chronic health problems, and recent 
use of other health services. Each IAH patient will receive a 
comprehensive assessment at least annually. The assessment will inform 
a plan for care that is directed by an IAH physician, nurse-
practitioner, or physician's assistant. The plan is developed by an IAH 
plan coordinator in collaboration with the patient and caregiver. 
Medication management is provided by pharmacists due to their expertise 
in pharmacology, and electronic medical records and health information 
technology will be employed to improve patient care and reduce costs.
  The two-phase pilot program will take place in the thirteen highest-
cost states plus thirteen additional states. After review of Phase I 
and the evaluation report, the Secretary may elect to expand the 
program nationwide so it could then become an ongoing benefit for 
Medicare beneficiaries.
  A shared-savings agreement incentive program allows this innovative 
delivery model to attract and maintain providers. The IAH organization 
will be required to demonstrate savings of at least 5 percent annually 
compared with the costs of serving non-participating Medicare 
chronically ill beneficiaries. The IAH organization may keep 80 percent 
of savings beyond the required 5 percent savings as an incentive to 
maximize the financial benefits of being an IAH organization. Any 
savings beyond 25 percent would be split, with 50 percent directed to 
the IAH organization and 50 percent to Medicare. In Phase II, the 
Secretary may modify the payment incentive structure to increase 
savings to the Medicare Trust Fund only if it will not impede access to 
IAH services to eligible beneficiaries.
  I would like to thank my fellow Senate cosponsors, Richard Burr, 
Sheldon Whitehouse, and Benjamin Cardin, and my cosponsor in the House, 
Representative Ed Markey, and his cosponsor, Chris Smith, for their 
support. I also thank Rahm Emanuel for his support of IAH in the last 
Congress. I would also like to thank all our staff who worked so hard 
on this legislation, particularly Gregory Hinrichsen in my office. 
Finally, I would like to thank the following groups for voicing their 
support for this legislation: The American Academy of Home Care 
Physicians; The American Academy of Neurology; The AARP; The 
Alzheimer's Association; The Alzheimer's Foundation of America; The 
American Academy of Nurse Practitioners; The American College of Nurse 
Practitioners; American Academy of Physician Assistants; The American 
Society of Consultant Pharmacists; The National Family Caregivers 
Association; The Family Caregiver Alliance/National Center on 
Caregiving; The American Association of Homes and Services for the 
Aging; The Housecalls Doctors of Texas; The Maryland-National Capital 
Home Care Association; The Visiting Nurse Associations of America; 
Housecall Providers, Inc. of Portland, OR; Intel Corp.; The National 
Council on Aging; U.S. PIRG; Massachusetts Neurologic Society; Naples 
Health Care Associates; Urban Medical House Calls of Boston, MA; MD2U 
Doctors Who Make Housecalls (Louisville, KY); Wyeth Pharmaceuticals.
  I urge all of my colleagues to support this important legislation to 
help Medicare patients get better care at lower cost.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows;

                                S. 1131

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Independence at Home Act of 
     2009''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) According to the November 2007 Congressional Budget 
     Office Long Term Outlook for Health Care Spending, unless 
     changes are made to the way health care is delivered, growing 
     demand for resources caused by rising health care costs and 
     to a lesser extent the nation's expanding elderly population 
     will confront Americans with increasingly difficult choices 
     between health care and other priorities. However, 
     opportunities exist to constrain health care costs without 
     adverse health care consequences.
       (2) Medicare beneficiaries with multiple chronic conditions 
     account for a disproportionate share of Medicare spending 
     compared to their representation in the overall Medicare 
     population, and evidence suggests that such patients often 
     receive poorly coordinated care, including conflicting 
     information from health providers and different diagnoses of 
     the same symptoms.
       (3) People with chronic conditions account for 76 percent 
     of all hospital admissions, 88 percent of all prescriptions 
     filled, and 72 percent of physician visits.
       (4) Studies show that hospital utilization and emergency 
     room visits for patients with multiple chronic conditions can 
     be reduced and significant savings can be achieved through 
     the use of interdisciplinary teams of health care 
     professionals caring for patients in their places of 
     residence.
       (5) The Independence at Home Act creates a chronic care 
     coordination pilot project to bring primary care medical 
     services to the highest cost Medicare beneficiaries with 
     multiple chronic conditions in their home or place of 
     residence so that they may be as independent as possible for 
     as long as possible in a comfortable setting.
       (6) The Independence at Home Act generates savings by 
     providing better, more coordinated care across all treatment 
     settings to the highest cost Medicare beneficiaries with 
     multiple chronic conditions, reducing duplicative and 
     unnecessary services, and avoiding unnecessary 
     hospitalizations, nursing home admissions, and emergency room 
     visits.
       (7) The Independence at Home Act holds providers 
     accountable for improving beneficiary outcomes, ensuring 
     patient and caregiver satisfaction, and achieving cost 
     savings to Medicare on an annual basis.
       (8) The Independence at Home Act creates incentives for 
     practitioners and providers to develop methods and 
     technologies for providing better and lower cost health care 
     to the highest cost Medicare beneficiaries with the greatest 
     incentives provided in the case of highest cost 
     beneficiaries.
       (9) The Independence at Home Act contains the central 
     elements of proven home-based primary care delivery models 
     that have been utilized for years by the Department of 
     Veterans Affairs and ``house calls'' programs across the 
     country to deliver coordinated care for chronic conditions in 
     the comfort of a patient's home or place of residence.

     SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE AT HOME 
                   CHRONIC CARE COORDINATION PILOT PROJECT UNDER 
                   TRADITIONAL MEDICARE FEE-FOR-SERVICE PROGRAM.

       (a) In General.--Title XVIII of the Social Security Act is 
     amended--
       (1) by amending subsection (c) of section 1807 (42 U.S.C. 
     1395b-8) to read as follows:
       ``(c) Independence at Home Chronic Care Coordination Pilot 
     Project.--A pilot project for Independence at Home chronic 
     care coordination programs for high cost Medicare 
     beneficiaries with multiple chronic conditions is set forth 
     in section 1807A.''; and
       (2) by inserting after section 1807 the following new 
     section:


     ``independence at home chronic care coordination pilot project

       ``Sec. 1807A.  (a) Implementation.--
       ``(1) In general.--The Secretary shall provide for the 
     phased in development, implementation, and evaluation of 
     Independence at Home programs described in this section to 
     meet the following objectives:
       ``(A) To improve patient outcomes, compared to comparable 
     beneficiaries who do not participate in such a program, 
     through reduced hospitalizations, nursing home admissions, or 
     emergency room visits, increased symptom self-management, and 
     similar results.
       ``(B) To improve satisfaction of patients and caregivers, 
     as demonstrated through a quantitative pre-test and post-test 
     survey developed by the Secretary that measures patient and 
     caregiver satisfaction of care coordination, educational 
     information, timeliness of response, and similar care 
     features.
       ``(C) To achieve a minimum of 5 percent cost savings in the 
     care of beneficiaries under this title suffering from 
     multiple high cost chronic diseases.
       ``(2) Initial implementation (phase i).--
       ``(A) In general.--In carrying out this section and to the 
     extent possible, the Secretary shall enter into agreements 
     with at least two unaffiliated Independence at Home 
     organizations in each of the 13 highest cost States (based on 
     average per capita expenditures per State under this title), 
     in the District of Columbia, and in 13 additional States that 
     are representative of other regions of the United States and 
     include medically underserved rural and urban areas, to 
     provide chronic care coordination services for a period of 
     three years or until those agreements are terminated by the 
     Secretary. Such agreements under this paragraph shall 
     continue in effect until the Secretary makes the 
     determination described in paragraph (3) or until those 
     agreements are supplanted by new agreements under such 
     paragraph. The phase of implementation under this paragraph 
     is

[[Page S5831]]

     referred to in this section as the `initial implementation' 
     phase or `phase I'.
       ``(B) Preference.--In selecting Independence at Home 
     organizations under this paragraph, the Secretary shall give 
     a preference, to the extent practicable, to organizations 
     that--
       ``(i) have documented experience in furnishing the types of 
     services covered by this section to eligible beneficiaries in 
     the home or place of residence using qualified teams of 
     health care professionals that are directed by individuals 
     who have the qualifications of Independence at Home 
     physicians, or in cases when such direction is provided by an 
     Independence at Home physician to a physician assistant who 
     has at least one year of experience providing gerontological 
     medical and related services for chronically ill individuals 
     in their homes, or other similar qualification as determined 
     by the Secretary to be appropriate for the Independence at 
     Home program, by the physician assistant acting under the 
     supervision of an Independence at Home physician and as 
     permitted under State law, or Independence at Home nurse 
     practitioners;
       ``(ii) have the capacity to provide services covered by 
     this section to at least 150 eligible beneficiaries; and
       ``(iii) use electronic medical records, health information 
     technology, and individualized plans of care.
       ``(3) Expanded implementation phase (phase ii).--
       ``(A) In general.--For periods beginning after the end of 
     the 3-year initial implementation period under paragraph (2), 
     subject to subparagraph (B), the Secretary shall renew 
     agreements described in paragraph (2) with Independence at 
     Home organization that have met all 3 objectives specified in 
     paragraph (1) and enter into agreements described in 
     paragraph (2) with any other organization that is located in 
     any State or the District of Columbia, that was not an 
     Independence at Home organization during the initial 
     implementation period, and that meets the qualifications of 
     an Independence at Home organization under this section. The 
     Secretary may terminate and not renew such an agreement with 
     an organization that has not met such objectives during the 
     initial implementation period. The phase of implementation 
     under this paragraph is referred to in this section as the 
     `expanded implementation' phase or `phase II'.
       ``(B) Contingency.--The expanded implementation under 
     subparagraph (A) shall not occur if the Secretary finds, not 
     later than 60 days after the date of issuance of the 
     independent evaluation under paragraph (5), that continuation 
     of the Independence at Home project is not in the best 
     interest of beneficiaries under this title or in the best 
     interest of Federal health care programs.
       ``(4) Eligibility.--No organization shall be prohibited 
     from participating under this section during expanded 
     implementation phase under paragraph (3) (and, to the extent 
     practicable, during initial implementation phase under 
     paragraph (2)) because of its small size as long as it meets 
     the eligibility requirements of this section.
       ``(5) Independent evaluations.--
       ``(A) In general.--The Secretary shall contract for an 
     independent evaluation of the initial implementation phase 
     under paragraph (2) with an interim report to Congress to be 
     provided on such evaluation as soon as practicable after the 
     first year of such phase and a final report to be provided to 
     Congress as soon as practicable following the conclusion of 
     the initial implementation phase, but not later than 6 months 
     following the end of such phase. Such an evaluation shall be 
     conducted by individuals with knowledge of chronic care 
     coordination programs for the targeted patient population and 
     demonstrated experience in the evaluation of such programs.
       ``(B) Information to be included.--Each such report shall 
     include an assessment of the following factors and shall 
     identify the characteristics of individual Independence at 
     Home programs that are the most effective in producing 
     improvements in--
       ``(i) beneficiary, caregiver, and provider satisfaction;
       ``(ii) health outcomes appropriate for patients with 
     multiple chronic diseases; and
       ``(iii) cost savings to the program under this title, such 
     as in reducing--

       ``(I) hospital and skilled nursing facility admission rates 
     and lengths of stay;
       ``(II) hospital readmission rates; and
       ``(III) emergency department visits

       ``(C) Breakdown by condition.--Each such report shall 
     include data on performance of Independence at Home 
     organizations in responding to the needs of eligible 
     beneficiaries with specific chronic conditions and 
     combinations of conditions, as well as the overall eligible 
     beneficiary population.
       ``(6) Agreements.--
       ``(A) In general.--The Secretary shall enter into 
     agreements, beginning not later than one year after the date 
     of the enactment of this section, with Independence at Home 
     organizations that meet the participation requirements of 
     this section, including minimum performance standards 
     developed under subsection (e)(3), in order to provide access 
     by eligible beneficiaries to Independence at Home programs 
     under this section.
       ``(B) Authority.--If the Secretary deems it necessary to 
     serve the best interest of the beneficiaries under this title 
     or the best interest of Federal health care programs, the 
     Secretary may--
       ``(i) require screening of all potential Independence at 
     Home organizations, including owners, (such as through 
     fingerprinting, licensure checks, site-visits, and other 
     database checks) before entering into an agreement;
       ``(ii) require a provisional period during which a new 
     Independence at Home organization would be subject to 
     enhanced oversight (such as prepayment review, unannounced 
     site visits, and payment caps); and
       ``(iii) require applicants to disclose previous affiliation 
     with entities that have uncollected Medicare or Medicaid 
     debt, and authorize the denial of enrollment if the Secretary 
     determines that these affiliations pose undue risk to the 
     program.
       ``(7) Regulations.--At least three months before entering 
     into the first agreement under this section, the Secretary 
     shall publish in the Federal Register the specifications for 
     implementing this section. Such specifications shall describe 
     the implementation process from initial to final 
     implementation phases, including how the Secretary will 
     identify and notify potential enrollees and how and when 
     beneficiaries may enroll and disenroll from Independence at 
     Home programs and change the programs in which they are 
     enrolled.
       ``(8) Periodic progress reports.--Semi-annually during the 
     first year in which this section is implemented and annually 
     thereafter during the period of implementation of this 
     section, the Secretary shall submit to the Committees on Ways 
     and Means and Energy and Commerce of the House of 
     Representatives and the Committee on Finance of the Senate a 
     report that describes the progress of implementation of this 
     section and explaining any variation from the Independence at 
     Home program as described in this section.
       ``(9) Annual best practices conference.--During the initial 
     implementation phase and to the extent practicable at 
     intervals thereafter, the Secretary shall provide for an 
     annual Independence at Home teleconference for Independence 
     at Home organizations to share best practices and review 
     treatment interventions and protocols that were successful in 
     meeting all 3 objectives specified in paragraph (1).
       ``(b) Definitions.--For purposes of this section:
       ``(1) Activities of daily living.--The term `activities of 
     daily living' means bathing, dressing, grooming, 
     transferring, feeding, or toileting.
       ``(2) Caregiver.--The term `caregiver' means, with respect 
     to an individual with a qualifying functional impairment, a 
     family member, friend, or neighbor who provides assistance to 
     the individual.
       ``(3) Eligible beneficiary.--
       ``(A) In general.--The term `eligible beneficiary' means, 
     with respect to an Independence at Home program, an 
     individual who--
       ``(i) is entitled to benefits under part A and enrolled 
     under part B, but not enrolled in a plan under part C;
       ``(ii) has a qualifying functional impairment and has been 
     diagnosed with two or more of the chronic conditions 
     described in subparagraph (C); and
       ``(iii) within the 12 months prior to the individual first 
     enrolling with an Independence at Home program under this 
     section, has received benefits under part A for the following 
     services:

       ``(I) Non-elective inpatient hospital services.
       ``(II) Services in the emergency department of a hospital.
       ``(III) Any one of the following:

       ``(aa) Skilled nursing or sub-acute rehabilitation services 
     in a Medicare-certified nursing facility.
       ``(bb) Comprehensive acute rehabilitation facility or 
     Comprehensive outpatient rehabilitation facility services.
       ``(cc) Skilled nursing or rehabilitation services through a 
     Medicare-certified home health agency.
       ``(B) Disqualifications.--Such term does not include an 
     individual--
       ``(i) who is receiving benefits under section 1881;
       ``(ii) who is enrolled in a PACE program under section 
     1894;
       ``(iii) who is enrolled in (and is not disenrolled from) a 
     chronic care improvement program under section 1807;
       ``(iv) who within a 12-month period has been a resident for 
     more than 90 days in a skilled nursing facility, a nursing 
     facility (as defined in section 1919), or any other facility 
     identified by the Secretary;
       ``(v) who resides in a setting that presents a danger to 
     the safety of in-home health care providers and primary 
     caregivers; or
       ``(vi) whose enrollment in an Independence at Home program 
     the Secretary determines would be inappropriate.
       ``(C) Chronic conditions described.--The chronic conditions 
     described in this subparagraph are the following:
       ``(i) Congestive heart failure.
       ``(ii) Diabetes.
       ``(iii) Chronic obstructive pulmonary disease.
       ``(iv) Ischemic heart disease.
       ``(v) Peripheral arterial disease.
       ``(vi) Stroke.
       ``(vii) Alzheimer's Disease and other dementias designated 
     by the Secretary.
       ``(viii) Pressure ulcers.
       ``(ix) Hypertension.
       ``(x) Neurodegenerative diseases designated by the 
     Secretary which result in high costs under this title, 
     including amyotropic lateral sclerosis (ALS), multiple 
     sclerosis, and Parkinson's disease.

[[Page S5832]]

       ``(xi) Any other chronic condition that the Secretary 
     identifies as likely to result in high costs to the program 
     under this title when such condition is present in 
     combination with one or more of the chronic conditions 
     specified in the preceding clauses.
       ``(4) Independence at home assessment.--The term 
     `Independence at Home assessment' means a determination of 
     eligibility of an individual for an Independence at Home 
     program as an eligible beneficiary (as defined in paragraph 
     (3)), a comprehensive medical history, physical examination, 
     and assessment of the beneficiary's clinical and functional 
     status that--
       ``(A) is conducted in person by an individual--
       ``(i) who--

       ``(I) is an Independence at Home physician or an 
     Independence at Home nurse practitioner; or
       ``(II) a physician assistant, nurse practitioner, or 
     clinical nurse specialist, as defined in section 1861(aa)(5), 
     who is employed by an Independence at Home organization and 
     is supervised by an Independence at Home physician or 
     Independence at Home nurse practitioner; and

       ``(ii) does not have an ownership interest in the 
     Independence at Home organization unless the Secretary 
     determines that it is impracticable to preclude such 
     individual's involvement; and
       ``(B) includes an assessment of--
       ``(i) activities of daily living and other co-morbidities;
       ``(ii) medications and medication adherence;
       ``(iii) affect, cognition, executive function, and presence 
     of mental disorders;
       ``(iv) functional status, including mobility, balance, 
     gait, risk of falling, and sensory function;
       ``(v) social functioning and social integration;
       ``(vi) environmental needs and a safety assessment;
       ``(vii) the ability of the beneficiary's primary caregiver 
     to assist with the beneficiary's care as well as the 
     caregiver's own physical and emotional capacity, education, 
     and training;
       ``(viii) whether, in the professional judgment of the 
     individual conducting the assessment, the beneficiary is 
     likely to benefit from an Independence at Home program;
       ``(ix) whether the conditions in the beneficiary's home or 
     place of residence would permit the safe provision of 
     services in the home or residence, respectively, under an 
     Independence at Home program;
       ``(x) whether the beneficiary has a designated primary care 
     physician whom the beneficiary has seen in an office-based 
     setting within the previous 12 months; and
       ``(xi) other factors determined appropriate by the 
     Secretary.
       ``(5) Independence at home care team.--The term 
     `Independence at Home care team'--
       ``(A) means, with respect to a participant, a team of 
     qualified individuals that provides services to the 
     participant as part of an Independence at Home program; and
       ``(B) includes an Independence at Home physician or an 
     Independence at Home nurse practitioner and an Independence 
     at Home coordinator (who may also be an Independence at Home 
     physician or an Independence at Home nurse practitioner).
       ``(6) Independence at home coordinator.--The term 
     `Independence at Home coordinator' means, with respect to a 
     participant, an individual who--
       ``(A) is employed by an Independence at Home organization 
     and is responsible for coordinating all of the services of 
     the participant's Independence at Home plan;
       ``(B) is a licensed health professional, such as a 
     physician, registered nurse, nurse practitioner, clinical 
     nurse specialist, physician assistant, or other health care 
     professional as the Secretary determines appropriate, who has 
     at least one year of experience providing and coordinating 
     medical and related services for individuals in their homes; 
     and
       ``(C) serves as the primary point of contact responsible 
     for communications with the participant and for facilitating 
     communications with other health care providers under the 
     plan.
       ``(7) Independence at home organization.--The term 
     `Independence at Home organization' means a provider of 
     services, a physician or physician group practice, a nurse 
     practitioner or nurse practitioner group practice which 
     receives payment for services furnished under this title 
     (other than only under this section) and which--
       ``(A) has entered into an agreement under subsection (a)(2) 
     to provide an Independence at Home program under this 
     section;
       ``(B)(i) provides all of the services of the Independence 
     at Home plan in a participant's home or place of residence, 
     or
       ``(ii) if the organization is not able to provide all such 
     services in such home or residence, has adequate mechanisms 
     for ensuring the provision of such services by one or more 
     qualified entities;
       ``(C) has Independence at Home physicians, clinical nurse 
     specialists, nurse practitioners, or physician assistants 
     available to respond to patient emergencies 24 hours a day, 
     seven days a week;
       ``(D) accepts all eligible beneficiaries from the 
     organization's service area, as determined under the 
     agreement with the Secretary under this section, except to 
     the extent that qualified staff are not available; and
       ``(E) meets other requirements for such an organization 
     under this section.
       ``(8) Independence at home physician.--The term 
     `Independence at Home physician' means a physician who--
       ``(A) is employed by or affiliated with an Independence at 
     Home organization, as required under paragraph (7)(C), or has 
     another contractual relationship with the Independence at 
     Home organization that requires the physician to make in-home 
     visits and to be responsible for the plans of care for the 
     physician's patients;
       ``(B) is certified--
       ``(i) by the American Board of Family Physicians, the 
     American Board of Internal Medicine, the American Osteopathic 
     Board of Family Physicians, the American Osteopathic Board of 
     Internal Medicine, the American Board of Emergency Medicine, 
     or the American Board of Physical Medicine and 
     Rehabilitation; or
       ``(ii) by a Board recognized by the American Board of 
     Medical Specialties and determined by the Secretary to be 
     appropriate for the Independence at Home program;
       ``(C) has--
       ``(i) a certification in geriatric medicine as provided by 
     American Board of Medical Specialties; or
       ``(ii) passed the clinical competency examination of the 
     American Academy of Home Care Physicians and has substantial 
     experience in the delivery of medical care in the home, 
     including at least two years of experience in the management 
     of Medicare patients and one year of experience in home-based 
     medical care including at least 200 house calls; and
       ``(D) has furnished services during the previous 12 months 
     for which payment is made under this title.
       ``(9) Independence at home nurse practitioner.--The term 
     `Independence at Home nurse practitioner' means a nurse 
     practitioner who--
       ``(A) is employed by or affiliated with an Independence at 
     Home organization, as required under paragraph (7)(C), or has 
     another contractual relationship with the Independence at 
     Home organization that requires the nurse practitioner to 
     make in-home visits and to be responsible for the plans of 
     care for the nurse practitioner's patients;
       ``(B) practices in accordance with State law regarding 
     scope of practice for nurse practitioners;
       ``(C) is certified--
       ``(i) as a Gerontologic Nurse Practitioner by the American 
     Academy of Nurse Practitioners Certification Program or the 
     American Nurses Credentialing Center; or
       ``(ii) as a family nurse practitioner or adult nurse 
     practitioner by the American Academy of Nurse Practitioners 
     Certification Board or the American Nurses Credentialing 
     Center and holds a certificate of Added Qualification in 
     gerontology, elder care or care of the older adult provided 
     by the American Academy of Nurse Practitioners, the American 
     Nurses Credentialing Center or a national nurse practitioner 
     certification board deemed by the Secretary to be appropriate 
     for an Independence at Home program; and
       ``(D) has furnished services during the previous 12 months 
     for which payment is made under this title.
       ``(10) Independence at home plan.--The term `Independence 
     at Home plan' means a plan established under subsection 
     (d)(2) for a specific participant in an Independence at Home 
     program.
       ``(11) Independence at home program.--The term 
     `Independence at Home program' means a program described in 
     subsection (d) that is operated by an Independence at Home 
     organization.
       ``(12) Participant.--The term `participant' means an 
     eligible beneficiary who has voluntarily enrolled in an 
     Independence at Home program.
       ``(13) Qualified entity.--The term `qualified entity' means 
     a person or organization that is licensed or otherwise 
     legally permitted to provide the specific service (or 
     services) provided under an Independence at Home plan that 
     the entity has agreed to provide.
       ``(14) Qualifying functional impairment.--The term 
     `qualifying functional impairment' means an inability to 
     perform, without the assistance of another person, two or 
     more activities of daily living.
       ``(15) Qualified individual.--The term `qualified 
     individual' means a individual that is licensed or otherwise 
     legally permitted to provide the specific service (or 
     services) under an Independence at Home plan that the 
     individual has agreed to provide.
       ``(c) Identification and Enrollment of Prospective Program 
     Participants.--
       ``(1) Notice to eligible independence at home 
     beneficiaries.--The Secretary shall develop a model notice to 
     be made available to Medicare beneficiaries (and to their 
     caregivers) who are potentially eligible for an Independence 
     at Home program by participating providers and by 
     Independence at Home programs. Such notice shall include the 
     following information:
       ``(A) A description of the potential advantages to the 
     beneficiary participating in an Independence at Home program.
       ``(B) A description of the eligibility requirements to 
     participate.
       ``(C) Notice that participation is voluntary.
       ``(D) A statement that all other Medicare benefits remain 
     available to beneficiaries who enroll in an Independence at 
     Home program.

[[Page S5833]]

       ``(E) Notice that those who enroll in an Independence at 
     Home program will be responsible for copayments for house 
     calls made by Independence at Home physicians, physician 
     assistants, or by Independence at Home nurse practitioners, 
     except that such copayments may be reduced or eliminated at 
     the discretion of the Independence at Home physician, 
     physician assistant, or Independence at Home nurse 
     practitioner involved in accordance with subsection (f).
       ``(F) A description of the services that could be provided.
       ``(G) A description of the method for participating, or 
     withdrawing from participation, in an Independence at Home 
     program or becoming no longer eligible to so participate.
       ``(2) Voluntary participation and choice.--An eligible 
     beneficiary may participate in an Independence at Home 
     program through enrollment in such program on a voluntary 
     basis and may terminate such participation at any time. Such 
     a beneficiary may also receive Independence at Home services 
     from the Independence at Home organization of the 
     beneficiary's choice but may not receive Independence at Home 
     services from more than one Independence at Home organization 
     at a time.
       ``(d) Independence at Home Program Requirements.--
       ``(1) In general.--Each Independence at Home program shall, 
     for each participant enrolled in the program--
       ``(A) designate--
       ``(i) an Independence at Home physician or an Independence 
     at Home nurse practitioner; and
       ``(ii) an Independence at Home coordinator;
       ``(B) have a process to ensure that the participant 
     received an Independence at Home assessment before enrollment 
     in the program;
       ``(C) with the participation of the participant (or the 
     participant's representative or caregiver), an Independence 
     at Home physician, a physician assistant under the 
     supervision of an Independence at Home physician and as 
     permitted under State law, or an Independence at Home nurse 
     practitioner, and the Independence at Home coordinator, 
     develop an Independence at Home plan for the participant in 
     accordance with paragraph (2);
       ``(D) ensure that the participant receives an Independence 
     at Home assessment at least every 6 months after the original 
     assessment to ensure that the Independence at Home plan for 
     the participant remains current and appropriate;
       ``(E) implement all of the services under the participant's 
     Independence at Home plan and in instances in which the 
     Independence at Home organization does not provide specific 
     services within the Independence at Home plan, ensure that 
     qualified entities successfully provide those specific 
     services; and
       ``(F) provide for an electronic medical record and 
     electronic health information technology to coordinate the 
     participant's care and to exchange information with the 
     Medicare program and electronic monitoring and communication 
     technologies and mobile diagnostic and therapeutic 
     technologies as appropriate and accepted by the participant.
       ``(2) Independence at home plan.--
       ``(A) In general.--An Independence at Home plan for a 
     participant shall be developed with the participant, an 
     Independence at Home physician, a physician assistant under 
     the supervision of an Independence at Home physician and as 
     permitted under State law, an Independence at Home nurse 
     practitioner, or an Independence at Home coordinator, and, if 
     appropriate, one or more of the participant's caregivers and 
     shall--
       ``(i) document the chronic conditions, co-morbidities, and 
     other health needs identified in the participant's 
     Independence at Home assessment;
       ``(ii) determine which services under an Independence at 
     Home plan described in subparagraph (C) are appropriate for 
     the participant; and
       ``(iii) identify the qualified entity responsible for 
     providing each service under such plan.
       ``(B) Communication of individualized independence at home 
     plan to the independence at home coordinator.--If the 
     individual responsible for conducting the participant's 
     Independence at Home assessment and developing the 
     Independence at Home plan is not the participant's 
     Independence at Home coordinator, the Independence at Home 
     physician or Independence at Home nurse practitioner is 
     responsible for ensuring that the participant's Independence 
     at Home coordinator has such plan and is familiar with the 
     requirements of the plan and has the appropriate contact 
     information for all of the members of the Independence at 
     Home care team.
       ``(C) Services provided under an independence at home 
     plan.--An Independence at Home organization shall coordinate 
     and make available through referral to a qualified entity the 
     services described in the following clauses (i) through (iii) 
     to the extent they are needed and covered by under this title 
     and shall provide the care coordination services described in 
     the following clause (iv) to the extent they are appropriate 
     and accepted by a participant:
       ``(i) Primary care services, such as physician visits, 
     diagnosis, treatment, and preventive services.
       ``(ii) Home health services, such as skilled nursing care 
     and physical and occupational therapy.
       ``(iii) Phlebotomy and ancillary laboratory and imaging 
     services, including point of care laboratory and imaging 
     diagnostics.
       ``(iv) Care coordination services, consisting of--

       ``(I) Monitoring and management of medications by a 
     pharmacist who is certified in geriatric pharmacy by the 
     Commission for Certification in Geriatric Pharmacy or 
     possesses other comparable certification demonstrating 
     knowledge and expertise in geriatric pharmacotherapy, as well 
     as assistance to participants and their caregivers with 
     respect to selection of a prescription drug plan under part D 
     that best meets the needs of the participant's chronic 
     conditions.
       ``(II) Coordination of all medical treatment furnished to 
     the participant, regardless of whether such treatment is 
     covered and available to the participant under this title.
       ``(III) Self-care education and preventive care consistent 
     with the participant's condition.
       ``(IV) Education for primary caregivers and family members.
       ``(V) Caregiver counseling services and information about, 
     and referral to, other caregiver support and health care 
     services in the community.
       ``(VI) Referral to social services, such as personal care, 
     meals, volunteers, and individual and family therapy.
       ``(VII) Information about, and access to, hospice care.
       ``(VIII) Pain and palliative care and end-of-life care, 
     including information about developing advanced directives 
     and physicians orders for life sustaining treatment.

       ``(3) Primary treatment role within an independence at home 
     care team.--An Independence at Home physician, a physician 
     assistant under the supervision of an Independence at Home 
     physician and as permitted under State law, or an 
     Independence at Home nurse practitioner may assume the 
     primary treatment role as permitted under State law.
       ``(4) Additional responsibilities.--
       ``(A) Outcomes report.--Each Independence at Home 
     organization offering an Independence at Home program shall 
     monitor and report to the Secretary, in a manner specified by 
     the Secretary, on--
       ``(i) patient outcomes;
       ``(ii) beneficiary, caregiver, and provider satisfaction 
     with respect to coordination of the participant's care; and
       ``(iii) the achievement of mandatory minimum savings 
     described in subsection (e)(6).
       ``(B) Additional requirements.--Each such organization and 
     program shall provide the Secretary with listings of 
     individuals employed by the organization, including contract 
     employees, and individuals with an ownership interest in the 
     organization and comply with such additional requirements as 
     the Secretary may specify.
       ``(e) Terms and Conditions.--
       ``(1) In general.--An agreement under this section with an 
     Independence at Home organization shall contain such terms 
     and conditions as the Secretary may specify consistent with 
     this section.
       ``(2) Clinical, quality improvement, and financial 
     requirements.--The Secretary may not enter into an agreement 
     with such an organization under this section for the 
     operation of an Independence at Home program unless--
       ``(A) the program and organization meet the requirements of 
     subsection (d), minimum quality and performance standards 
     developed under paragraph (3), and such clinical, quality 
     improvement, financial, program integrity, and other 
     requirements as the Secretary deems to be appropriate for 
     participants to be served; and
       ``(B) the organization demonstrates to the satisfaction of 
     the Secretary that the organization is able to assume 
     financial risk for performance under the agreement with 
     respect to payments made to the organization under such 
     agreement through available reserves, reinsurance, or 
     withholding of funding provided under this title, or such 
     other means as the Secretary determines appropriate.
       ``(3) Minimum quality and performance standards.--
       ``(A) In general.--The Secretary shall develop mandatory 
     minimum quality and performance standards for Independence at 
     Home organizations and programs.
       ``(B) Standards to be included.--Such standards shall 
     include measures of--
       ``(i) improvement in participant outcomes;
       ``(ii) improvement in satisfaction of the beneficiary, 
     caregiver, and provider involved; and
       ``(iii) cost savings consistent with paragraph (6).
       ``(C) Minimum participation standard.--Such standards shall 
     include a requirement that, for any year after the first year 
     and except as the Secretary may provide for a program serving 
     a rural area, an Independence at Home program had an average 
     number of participants during the previous year of at least 
     100 participants.
       ``(4) Term of agreement and modification.--The agreement 
     under this subsection shall be, subject to paragraphs (3)(C) 
     and (5), for a period of three years, and the terms and 
     conditions may be modified during the contract period by the 
     Secretary as necessary to serve the best interest of the 
     beneficiaries under this title or the best interest of 
     Federal health care programs or upon the request of the 
     Independence at Home organization.
       ``(5) Termination and non-renewal of agreement.--

[[Page S5834]]

       ``(A) In general.--If the Secretary determines that an 
     Independence at Home organization has failed to meet the 
     minimum performance standards under paragraph (3) or other 
     requirements under this section, or if the Secretary deems it 
     necessary to serve the best interest of the beneficiaries 
     under this title or the best interest of Federal health care 
     programs, the Secretary may terminate the agreement of the 
     organization at the end of the contract year.
       ``(B) Required termination where risk to health or safety 
     of a participant.--The Secretary shall terminate an agreement 
     with an Independence at Home organization at any time the 
     Secretary determines that the care being provided by such 
     organization poses a threat to the health and safety of a 
     participant.
       ``(C) Termination by independence at home organizations.--
     Notwithstanding any other provision of this subsection, an 
     Independence at Home organization may terminate an agreement 
     with the Secretary under this section to provide an 
     Independence at Home program at the end of a contract year if 
     the organization provides to the Secretary and to the 
     beneficiaries participating in the program notification of 
     such termination more than 90 days before the end of such 
     year. Paragraphs (6), (8), and (9)(B) shall apply to the 
     organization until the date of termination.
       ``(D) Notice of involuntary termination.--The Secretary 
     shall notify the participants in an Independence at Home 
     program as soon as practicable if a determination is made to 
     terminate an agreement with the Independence at Home 
     organization involuntarily as provided in subparagraphs (A) 
     and (B). Such notice shall inform the beneficiary of any 
     other Independence at Home organizations that might be 
     available to the beneficiary.
       ``(6) Mandatory minimum savings.--
       ``(A) Required.--
       ``(i) In general.--Under an agreement under this 
     subsection, each Independence at Home organization shall 
     ensure that during any year of the agreement for its 
     Independence at Home program, there is an aggregate savings 
     in the cost to the program under this title for participating 
     beneficiaries, as calculated under subparagraph (B), that is 
     not less than 5 percent of the product described in clause 
     (ii) for such participating beneficiaries and year.
       ``(ii) Product described.--The product described in this 
     clause for participating beneficiaries in an Independence at 
     Home program for a year is the product of--

       ``(I) the estimated average monthly costs that would have 
     been incurred under parts A and B (and, to the extent cost 
     information is available, part D) if those beneficiaries had 
     not participated in the Independence at Home program; and
       ``(II) the number of participant-months for that year.

       ``(B) Computation of aggregate savings.--
       ``(i) Model for calculating savings.--The Secretary shall 
     contract with a nongovernmental organization or academic 
     institution to independently develop an analytical model for 
     determining whether an Independence at Home program achieves 
     at least savings required under subparagraph (A) relative to 
     costs that would have been incurred by Medicare in the 
     absence of Independence at Home programs. The analytical 
     model developed by the independent research organization for 
     making these determinations shall utilize state-of-the-art 
     econometric techniques, such as Heckman's selection 
     correction methodologies, to account for sample selection 
     bias, omitted variable bias, or problems with endogeneity.
       ``(ii) Application of the model.--Using the model developed 
     under clause (i), the Secretary shall compare the actual 
     costs to Medicare of beneficiaries participating in an 
     Independence at Home program to the predicted costs to 
     Medicare of such beneficiaries to determine whether an 
     Independence at Home program achieves the savings required 
     under subparagraph (A).
       ``(iii) Revisions of the model.--The Secretary shall 
     require that the model developed under clause (i) for 
     determining savings shall be designed according to 
     instructions that will control, or adjust for, inflation as 
     well as risk factors including, age, race, gender, disability 
     status, socioeconomic status, region of country (such as 
     State, county, metropolitan statistical area, or zip code), 
     and such other factors as the Secretary determines to be 
     appropriate, including adjustment for prior health care 
     utilization. The Secretary may add to, modify, or substitute 
     for such adjustment factors if such changes will improve the 
     sensitivity or specificity of the calculation of costs 
     savings.
       ``(iv) Participant-month.--In making the calculation 
     described in subparagraph (A), each month or part of a month 
     in a program year that a beneficiary participates in an 
     Independence at Home program shall be counted as a 
     `participant-month'.
       ``(C) Notice of savings calculation.--No later than 30 days 
     before the beginning of the first year of the pilot project 
     under this section and 120 days before the beginning of any 
     Independence at Home program year after the first such year, 
     the Secretary shall publish in the Federal Register a 
     description of the model developed under subparagraph (B)(i) 
     and information for calculating savings required under 
     subparagraph (A), including any revisions, sufficient to 
     permit Independence at Home organizations to determine the 
     savings they will be required to achieve during the program 
     year to meet the savings requirement under subparagraph (A). 
     In order to facilitate this notice, the Secretary may 
     designate a single annual date for the beginning of all 
     Independence at Home program years that shall not be later 
     than one year from the date of enactment of this section.
       ``(7) Manner of payment.--Subject to paragraph (8), 
     payments shall be made by the Secretary to an Independence at 
     Home organization at a rate negotiated between the Secretary 
     and the organization under the agreement for--
       ``(A) Independence at Home assessments; and
       ``(B) on a per-participant, per-month basis for the items 
     and services required to be provided or made available under 
     subsection (d)(2)(C)(iv).
       ``(8) Ensuring mandatory minimum savings.--The Secretary 
     shall require any Independence at Home organization that 
     fails in any year to achieve the mandatory minimum savings 
     described in paragraph (6) to provide those savings by 
     refunding payments made to the organization under paragraph 
     (7) during such year.
       ``(9) Budget neutral payment condition.--
       ``(A) In general.--Under this section, the Secretary shall 
     ensure that the cumulative, aggregate sum of Medicare program 
     benefit expenditures under parts A, B, and D for participants 
     in Independence at Home programs and funds paid to 
     Independence at Home organizations under this section, shall 
     not exceed the Medicare program benefit expenditures under 
     such parts that the Secretary estimates would have been made 
     for such participants in the absence of such programs.
       ``(B) Treatment of savings.--
       ``(i) Initial implementation phase.--If an Independence at 
     Home organization achieves aggregate savings in a year in the 
     initial implementation phase in excess of the mandatory 
     minimum savings described in paragraph (6)(A)(ii), 80 percent 
     of such aggregate savings shall be paid to the organization 
     and the remainder shall be retained by the programs under 
     this title during the initial implementation phase.
       ``(ii) Expanded implementation phase.--If an Independence 
     at Home organization achieves aggregate savings in a year in 
     the expanded implementation phase in excess of 5 percent of 
     the product described in paragraph (6)(A)(ii)--

       ``(I) insofar as such savings do not exceed 25 percent of 
     such product, 80 percent of such aggregate savings shall be 
     paid to the organization and the remainder shall be retained 
     by the programs under this title; and.
       ``(II) insofar as such savings exceed 25 percent of such 
     product, in the Secretary's discretion, 50 percent of such 
     excess aggregate savings shall be paid to the organization 
     and the remainder shall be retained by the programs under 
     this title.

       ``(f) Waiver of Coinsurance for House Calls.--A physician, 
     physician assistant, or nurse practitioner furnishing 
     services related to the Independence at Home program in the 
     home or residence of a participant in an Independence at Home 
     program may waive collection of any coinsurance that might 
     otherwise be payable under section 1833(a) with respect to 
     such services but only if the conditions described in section 
     1128A(i)(6)(A) are met.
       ``(g) Report.--Not later than three months after the date 
     of receipt of the independent evaluation provided under 
     subsection (a)(5) and each year thereafter during which this 
     section is being implemented, the Secretary shall submit to 
     the Committees of jurisdiction in Congress a report that 
     shall include--
       ``(1) whether the Independence at Home programs under this 
     section are meeting the minimum quality and performance 
     standards in (e)(3);
       ``(2) a comparative evaluation of Independence at Home 
     organizations in order to identify which programs, and 
     characteristics of those programs, were the most effective in 
     producing the best participant outcomes, patient and 
     caregiver satisfaction, and cost savings; and
       ``(3) an evaluation of whether the participant eligibility 
     criteria identified beneficiaries who were in the top ten 
     percent of the highest cost Medicare beneficiaries.''.
       (b) Conforming Amendment.--Section 1833(a) of such Act (42 
     U.S.C. 1395l(a)) is amended, in the matter before paragraph 
     (1), by inserting ``and section 1807A(f)'' after ``section 
     1876''.
                                 ______
                                 
      By Mr. LEAHY:
  S. 1132. A bill to amend title 18, United States Code, to improve the 
provisions relating to the carrying of concealed weapons by law 
enforcement officers, and for other purposes; to the Committee on the 
Judiciary.
  Mr. LEAHY. Mr. President, in 2003, Senator Ben Nighthorse Campbell 
and I, along with 68 other Senators, introduced a bill to allow 
qualified retired or current law enforcement officers to carry a 
concealed firearm across State lines. The Senate passed our bill by 
unanimous consent, and it was signed into law in July 2004. Passage of 
the Law Enforcement Officers Safety Act indicated strong confidence in 
the men and women who serve to protect their communities and their 
Nation as the first line of defense in any emergency.

[[Page S5835]]

  Introduction of this legislation to benefit active and retired law 
enforcement officers across the country is especially timely as the 
Congress and the country have just recognized National Peace Officers 
Memorial Day. I am proud to introduce this legislation today and thank 
Senator Kyl for joining me as a cosponsor.
  This year, the Senate Judiciary Committee has turned its attention to 
State and local law enforcement. It has held hearings about the 
importance of Federal funding at the local level, and how strong 
community policing and positive community relationships are fundamental 
to a prosperous economy. I agree, and appreciated having the 
perspective at recent Judiciary Committee hearings of the State and 
local officials like Chief Michael Schirling and Lieutenant Kris 
Carlson from the Burlington, Vermont, Police Department. I hope the 
Senate will continue its strong support of our law enforcement officers 
with support for this legislation.
  In 2007, the Senate Judiciary Committee twice reported the 
legislation I introduce today--once as a stand-alone bill and again as 
part of the School Safety and Law Enforcement Improvements Act. I hope 
the Senate will act in the interest of so many law enforcement officers 
across the United States by improving and building upon the current 
law.
  Since enactment of the Law Enforcement Officers Safety Act, I have 
heard feedback from many in law enforcement that qualified retired 
officers have been subject to varying certification procedures from 
State to State. In many cases, differing interpretations have 
complicated the implementation of the law, and retired officers have 
experienced significant frustration in getting certified to lawfully 
carry a firearm under the law.
  With the input of the law enforcement community, this bill proposes 
modest amendments to the current law, and will give retired officers 
more flexibility in obtaining certification. It also provides room for 
the variability in certification standards among the several States. 
For example, where a State has not set active duty standards, the 
retired officer can be certified pursuant to the standards set by a law 
enforcement agency in the State.
  In addition to these changes, the bill makes clear that Amtrak 
officers, along with law enforcement officers of the Executive branch 
of the Federal Government, are covered by the law. The bill also 
reduces the years of service required for a retired officer to qualify 
under the law from 15 to 10. The bill now contains clearer standards to 
address mental health issues related to eligibility for officers who 
separate from service or retire. These are positive changes to the 
current law, and the requirements for eligibility would continue to 
require a significant term of service for a retired officer to qualify, 
a demonstrated commitment to law enforcement, and retirement in good 
standing.
  The dedicated public servants who are trained to uphold the law and 
keep the peace deserve our support not just in their professional 
lives, but also when they are off-duty or retire. As a former 
prosecutor, I have great confidence in those who serve in law 
enforcement and their ability to exercise their privileges under this 
legislation safely and responsibly. The responsibilities they shoulder 
day to day on the job deserve our recognition and respect.
  I hope all Senators will join us in support of this legislation.
  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. 1132

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Law Enforcement Officers 
     Safety Act Improvements Act of 2009''.

     SEC. 2.

       (a) In General.--Section 926B of title 18, United States 
     Code, is amended by adding at the end the following:
       ``(f) For the purposes of this section, a law enforcement 
     officer of the Amtrak Police Department or a law enforcement 
     or police officer of the executive branch of the Federal 
     Government qualifies as an employee of a governmental agency 
     who is authorized by law to engage in or supervise the 
     prevention, detection, investigation, or prosecution of, or 
     the incarceration of any person for, any violation of law, 
     and has statutory powers of arrest.''.
       (b) Active Law Enforcement Officers.--Section 926B of title 
     18, United States Code is amended by striking subsection (e) 
     and inserting the following:
       ``(e) As used in this section, the term `firearm'--
       ``(1) except as provided in this subsection, has the same 
     meaning as in section 921 of this title;
       ``(2) includes ammunition not expressly prohibited by 
     Federal law or subject to the provisions of the National 
     Firearms Act; and
       ``(3) does not include--
       ``(A) any machinegun (as defined in section 5845 of the 
     National Firearms Act);
       ``(B) any firearm silencer (as defined in section 921 of 
     this title); and
       ``(C) any destructive device (as defined in section 921 of 
     this title).''.
       (c) Retired Law Enforcement Officers.--Section 926C of 
     title 18, United States Code is amended--
       (1) in subsection (c)--
       (A) in paragraph (1)--
       (i) by striking ``retired'' and inserting ``separated from 
     service''; and
       (ii) by striking ``, other than for reasons of mental 
     instability'';
       (B) in paragraph (2), by striking ``retirement'' and 
     inserting ``separation'';
       (C) in paragraph (3)--
       (i) in subparagraph (A), by striking ``retirement, was 
     regularly employed as a law enforcement officer for an 
     aggregate of 15 years or more'' and inserting ``separation, 
     served as a law enforcement officer for an aggregate of 10 
     years or more''; and
       (ii) in subparagraph (B), by striking ``retired'' and 
     inserting ``separated'';
       (D) by striking paragraph (4) and inserting the following:
       ``(4) during the most recent 12-month period, has met, at 
     the expense of the individual, the standards for 
     qualification in firearms training for active law enforcement 
     officers, as determined by the former agency of the 
     individual, the State in which the individual resides or, if 
     the State has not established such standards, a law 
     enforcement agency within the State in which the individual 
     resides;''; and
       (E) by striking paragraph (5) and replacing it with the 
     following:
       ``(5)(A) has not been officially found by a qualified 
     medical professional employed by the agency to be unqualified 
     for reasons relating to mental health and as a result of this 
     finding will not be issued the photographic identification as 
     described in subsection (d)(1); or
       ``(B) has not entered into an agreement with the agency 
     from which the individual is separating from service in which 
     that individual acknowledges he or she is not qualified under 
     this section for reasons relating to mental health and for 
     those reasons will not receive or accept the photographic 
     identification as described in subsection (d)(1);'';
       (2) in subsection (d)--
       (A) paragraph (1)--
       (i) by striking ``retired'' and inserting ``separated''; 
     and
       (ii) by striking ``to meet the standards'' and all that 
     follows through ``concealed firearm'' and inserting ``to meet 
     the active duty standards for qualification in firearms 
     training as established by the agency to carry a firearm of 
     the same type as the concealed firearm'';
       (B) paragraph (2)--
       (i) in subparagraph (A), by striking ``retired'' and 
     inserting ``separated''; and
       (ii) in subparagraph (B), by striking ``that indicates'' 
     and all that follows through the period and inserting ``or by 
     a certified firearms instructor that is qualified to conduct 
     a firearms qualification test for active duty officers within 
     that State that indicates that the individual has, not less 
     than 1 year before the date the individual is carrying the 
     concealed firearm, been tested or otherwise found by the 
     State or a certified firearms instructor that is qualified to 
     conduct a firearms qualification test for active duty 
     officers within that State to have met--

       ``(I) the active duty standards for qualification in 
     firearms training, as established by the State, to carry a 
     firearm of the same type as the concealed firearm; or
       ``(II) if the State has not established such standards, 
     standards set by any law enforcement agency within that State 
     to carry a firearm of the same type as the concealed 
     firearm.''; and

       (3) by striking subsection (e) and inserting the following:
       ``(e) As used in this section--
       ``(1) the term `firearm'--
       ``(A) except as provided in this paragraph, has the same 
     meaning as in section 921 of this title;
       ``(B) includes ammunition not expressly prohibited by 
     Federal law or subject to the provisions of the National 
     Firearms Act; and
       ``(C) does not include--
       ``(i) any machinegun (as defined in section 5845 of the 
     National Firearms Act);
       ``(ii) any firearm silencer (as defined in section 921 of 
     this title); and
       ``(iii) any destructive device (as defined in section 921 
     of this title); and
       ``(2) the term `service with a public agency as a law 
     enforcement officer' includes service as a law enforcement 
     officer of the Amtrak Police Department, or as a law 
     enforcement or police officer of the executive branch of the 
     Federal Government.''.

[[Page S5836]]

                                 ______
                                 
      By Mr. WYDEN (for himself and Mr. Gregg):
  S. 1133. A bill to amend title XVIII of the Social Security Act to 
provide for the establishment of shared decision making standards and 
requirements and to establish a pilot program for the implementation of 
shared decision making under the Medicare program; to the Committee on 
Finance.
  Mr. WYDEN. Mr. President, I am pleased to be joined by my colleague, 
the distinguished Senator from New Hampshire, Judd Gregg, to introduce 
an important bill that will put patients in the driver's seat of their 
medical care. Today, my fellow Oregonian Representative Earl Blumenauer 
is introducing the same bill in the House of Representatives.
  On the Senate floor and in the Finance Committee and Health Education 
Labor and Pensions Committee, senators have been wrestling with health 
reform. The challenge before the Congress is to both expand quality, 
affordable coverage to all Americans while containing costs.
  Cost containment requires a lot of tough choices because it will 
require changing how care is delivered. The time of paying for volume 
and low quality is past. Chairman Baucus rightly recognized the 
challenges in cost containment and took up this issue as the first area 
he wanted to address in the series of public roundtables held in the 
Finance Committee.
  I believe the key to transforming the health care system and cost 
containment is to give patients more choices. Patients should have more 
choices of health insurance plans. Patients should have a choice of 
doctor. Patients should also have choices in their medical care.
  The research by Dr. Jim Weinstein and Dr. John Wennberg with the 
Dartmouth Atlas Project has documented regional variations in medical 
care. They have found both underuse, or the failure to deliver needed 
evidence-based care, and overuse, or the delivery of unnecessary 
supply-sensitive care. Regional variations are driven by local medical 
opinion, rather than sound science or the preferences of well-informed 
patients. Just because doctors are licensed to have a hammer, doesn't 
make every patient a nail.
  Using their research, Office of Management and Budget Director Peter 
Orszag and other experts have estimated that as much as 30 percent of 
medical spending today goes to care that is unnecessary. That is 30 
percent of $2.5 trillion is $750 billion going to care that does not 
make patients healthier and may even harm them.
  The current standard of medical care in the U.S. fails to adequately 
ensure that patients are informed about all their treatment options and 
the risks and benefits of those options. This leads to patients getting 
medical treatments they may not have wanted had they been fully 
informed of their treatment options and integrated into the decision 
making process. In order to deliver the right care at the right time, 
informed patient choice should be the goal of medical care.
  Shared decision making is a collaborative process between the doctor 
and patient when they discuss the trade-offs among treatment options 
and discuss the patient's preferences and values. Shared decision 
making uses patient decision aids, an educational tool like a video or 
pamphlet that helps patients understand, communicate their beliefs and 
preferences related to their treatment options, and decide what medical 
treatments are best for them with their provider based on their medical 
treatment options, scientific evidence, circumstances, beliefs and 
preferences.
  Informed patients choice depends on clinical comparative 
effectiveness research that compares the effectiveness of health care 
treatments. Shared decision making and patient decision aids use 
clinical comparative effectiveness research so that doctors and 
patients together make the right medical treatment choice for each 
individual patient.
  This bill creates a three stage phase in of patient decision aids and 
shared decision making into the Medicare program. Phase I of the pilot 
is a 3-year period allowing `early adopting' providers--those who 
already have experience using patient decision aids and incorporating 
them into their clinical practices--to participate in the pilot 
providing data for the Secretary and also serve as Shared Decision 
Making Resource Centers. During this period, an independent entity will 
develop consensus based standards for patient decision aids and a 
certification process to ensure decision aids are effective and provide 
unbiased information. An expert panel then recommends to the Secretary 
which patient decision aids may be used in this program.
  Phase II is a 3-year period during which providers will be eligible 
to receive reimbursement for the use of certified patient decision 
aids. New providers may be added on an annual basis allowing for the 
gradual and voluntary expansion of shared decision making and patient 
decision aids to a large portion of the country.
  The final stage requires all Medicare providers to ensure that 
Medicare beneficiaries receive shared decision making and patient 
decision aids prior to receiving treatment for a preference sensitive 
condition. If a provider does not ensure that a patient receives a 
patient decision aid then the provider's reimbursement may be reduced 
by no more than 20 percent.
  This legislation is built on a shared savings model distributing 50 
percent of the savings to participating providers based on their 
participation and performance on quality measures. Twenty-five percent 
of the savings are used to expand provider participation providing 
financial support to the Shared Decision Making Centers and providers. 
The final 25 percent savings are returned to the Medicare program. As 
shared decision making becomes the standard of practice, the shared 
savings percentages phases out.
  I believe that this simple approach to informed patient choice is 
critically important to giving patients real choices by engaging them 
in their health care. As we look to expand access to health coverage, 
this bill provides a bipartisan, sensible path to putting patients in 
the driver's seat.
  I hope my colleagues will join me in supporting this bill, and I look 
forward to working with Chairman Baucus and Ranking Member Grassley and 
other members of the Finance Committee to secure passage of this 
important bill.
  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. 1133

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Empowering Medicare Patient 
     Choices Act''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) The Dartmouth Atlas Project's work documenting regional 
     variations in medical care has found both underuse, or the 
     failure to deliver needed evidence-based care, and overuse, 
     or the delivery of unnecessary supply-sensitive care.
       (2) The Dartmouth Atlas Project has also found that many 
     clinical decisions physicians make for elective medical 
     treatments are driven by local medical opinion, rather than 
     sound science or the preferences of well-informed patients. 
     For example, the Dartmouth Atlas Project found that, among 
     the 306 Hospital Referral Regions in the United States during 
     the period of 2002 through 2003, the incidence of surgery for 
     back pain-related conditions and joint replacement for 
     chronic arthritis of the hip and knee varied 5.9-, 5.6-, and 
     4.8-fold, respectively, from the lowest to the highest 
     region.
       (3) Discretionary surgery for the following common 
     conditions accounts for 40 percent of Medicare spending for 
     inpatient surgery: early stage cancer of the prostate; early 
     stage cancer of the breast; osteoarthritis of the knee; 
     osteoarthritis of the hip; osteoarthritis of the spine; chest 
     pain due to coronary artery disease; stroke threat from 
     carotid artery disease, ischemia due to peripheral artery 
     disease; gall stones; and enlarged prostate.
       (4) Decisions that involve values trade-offs between the 
     benefits and harms of 2 or more clinically appropriate 
     alternatives should depend on the individual patient's 
     informed choice. In everyday practice, however, patients 
     typically delegate decision making to their physicians who 
     may not have good information on the patient's true 
     preferences.
       (5) The current standard of medical care in the United 
     States fails to adequately ensure that patients are informed 
     about their treatment options and the risks and benefits of 
     those options. This leads to patients getting medical 
     treatments they may not have wanted had they been fully 
     informed of their treatment options and integrated into the 
     decision making process.
       (6) Patient decision aids are tools designed to help people 
     participate in decision making

[[Page S5837]]

     about health care options. Patient decision aids provide 
     information on treatment options and help patients clarify 
     and communicate the personal value they associate with 
     different features of treatment options. Patient decision 
     aids do not advise people to choose one treatment option over 
     another, nor are they meant to replace practitioner 
     consultation. Instead, they prepare patients to make 
     informed, value-based decisions with their physician.
       (7) The Lewin Group estimated that the change in spending 
     resulting from the use of patient decision aids for each of 
     11 conditions using per-procedure costs estimated for the 
     Medicare population studied, assuming full implementation of 
     such patient decision aids in 2010, would save as much as 
     $4,000,000,000.

     SEC. 3. DEFINITIONS.

       In this Act:
       (1) Eligible provider.--
       (A) In general.--The term ``eligible provider'' means the 
     following:
       (i) A primary care practice.
       (ii) A specialty practice.
       (iii) A multispecialty group practice.
       (iv) A hospital.
       (v) A rural health clinic.
       (vi) A Federally qualified health center (as defined in 
     section 1861(aa)(4) of the Social Security Act (42 U.S.C. 
     1395x(aa)(4)).
       (vii) An integrated delivery system.
       (viii) A State cooperative.
       (B) Inclusion of medicare advantage plans.--Such term 
     includes a Medicare Advantage plan offered by a Medicare 
     Advantage organization under part C of title XVIII of the 
     Social Security Act (42 U.S.C. 1395w-21 et seq.).
       (2) Patient decision aid.--The term ``patient decision 
     aid'' means an educational tool (such as the Internet, a 
     video, or a pamphlet) that helps patients (or, if 
     appropriate, the family caregiver of the patient) understand 
     and communicate their beliefs and preferences related to 
     their treatment options, and to decide with their health care 
     provider what treatments are best for them based on their 
     treatment options, scientific evidence, circumstances, 
     beliefs, and preferences.
       (3) Preference sensitive care.--The term ``preference 
     sensitive care'' means medical care for which the clinical 
     evidence does not clearly support one treatment option such 
     that the appropriate course of treatment depends on the 
     values of the patient or the preferences of the patient 
     regarding the benefits, harms, and scientific evidence for 
     each treatment option. The use of such care should depend on 
     informed patient choice among clinically appropriate 
     treatment options. Such term includes medical care for the 
     conditions identified in section 5(g).
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (5) Shared decision making.--The term ``shared decision 
     making'' means a collaborative process between patient and 
     clinician that engages the patient in decision making, 
     provides patients with information about trade-offs among 
     treatment options, and facilitates the incorporation of 
     patient preferences and values into the medical plan.
       (6) State cooperative.--The term ``State cooperative'' 
     means an entity that includes the State government and at 
     least one other health care provider which is set up for the 
     purpose of testing shared decision making and patient 
     decision aids.

     SEC. 4. ESTABLISHMENT OF INDEPENDENT STANDARDS FOR PATIENT 
                   DECISION AIDS.

       (a) Contract With Entity to Establish Standards and Certify 
     Patient Decision Aids.--
       (1) Contract.--
       (A) In general.--For purposes of supporting consensus-based 
     standards for patient decision aids and a certification 
     process for patient decision aids for use in the Medicare 
     program and by other interested parties, the Secretary shall 
     identify and have in effect a contract with an entity that 
     meets the requirements described in paragraph (4). Such 
     contract shall provide that the entity perform the duties 
     described in paragraph (2).
       (B) Timing for first contract.--As soon as practicable 
     after the date of the enactment of this Act, the Secretary 
     shall enter into the first contract under subparagraph (A).
       (C) Period of contract.--A contract under subparagraph (A) 
     shall be for a period of 18 months (except such contract may 
     be renewed after a subsequent bidding process).
       (D) Competitive procedures.--Competitive procedures (as 
     defined in section 4(5) of the Office of Federal Procurement 
     Policy Act (41 U.S.C. 403(5))) shall be used to enter into a 
     contract under subparagraph (A).
       (2) Duties.--The following duties are described in this 
     paragraph:
       (A) Operate an open and transparent process.--The entity 
     shall conduct its business in an open and transparent manner 
     and provide the opportunity for public comment on the 
     activities described in subparagraphs (B) and (C).
       (B) Establish standards for patient decision aids.--
       (i) In general.--The entity shall synthesize evidence and 
     convene a broad range of experts and key stakeholders to 
     establish consensus-based standards, such as those developed 
     by the International Patient Decision Aid Standard 
     Collaboration, to determine which patient decision aids are 
     high quality patient decision aids.
       (ii) Draft of proposed standards.--The entity shall make a 
     draft of proposed standards available to the public.
       (iii) 60-day comment period.--Beginning on the date the 
     entity makes a draft of the proposed standards available 
     under clause (ii), the entity shall provide a 60-day period 
     for public comment on such draft.
       (iv) Final standards.--

       (I) In general.--The standards established by the entity 
     under this subparagraph shall be adopted by the board of the 
     entity.
       (II) Public availability.--The entity shall make such 
     standards available to the public.

       (C) Certify patient decision aids.--The entity shall review 
     patient decision aids and certify whether patient decision 
     aids meet the standards established under subparagraph (B) 
     and offer a balanced presentation of treatment options from 
     both the clinical and patient experience perspectives. In 
     conducting such review and certification, the entity shall 
     give priority to the review and certification of patient 
     decision aids for conditions identified in section 5(g).
       (3) Report to the expert panel.--The entity shall submit to 
     the expert panel established under subsection (b) a report on 
     the standards established for patient decision aids under 
     paragraph (2)(B) and patient decision aids that are certified 
     as meeting such standards under paragraph (2)(C).
       (4) Requirements described.--The following requirements are 
     described in this paragraph:
       (A) Private nonprofit.--The entity is a private nonprofit 
     organization governed by a board.
       (B) Experience.--The entity shall be able to demonstrate 
     experience with--
       (i) consumer engagement;
       (ii) standard setting;
       (iii) health literacy;
       (iv) health care quality and safety issues;
       (v) certification processes;
       (vi) measure development; and
       (vii) evaluating health care quality.
       (C) Membership fees.--If the entity requires a membership 
     fee for participation in the functions of the entity, such 
     fees shall be reasonable and adjusted based on the capacity 
     of the potential member to pay the fee. In no case shall 
     membership fees pose a barrier to the participation of 
     individuals or groups with low or nominal resources to 
     participate in the functions of the entity.
       (b) Expert Panel.--
       (1) Establishment.--Not later than 120 days after the date 
     of enactment of this Act, the Secretary shall establish an 
     expert panel to make recommendations to the Secretary 
     regarding which patient decision aids should be implemented, 
     appropriate training for health care providers on patient 
     decision aids and shared decision making, and appropriate 
     quality measures for use in the pilot program under section 5 
     and under section 1899 of the Social Security Act, as added 
     by section 6.
       (2) Duties.--The expert panel shall carry out the following 
     duties:
       (A) Approve patient decision aids, from among those patient 
     decision aids certified under paragraph (2)(C) of subsection 
     (a) by the entity with a contract under such subsection, for 
     use in the pilot program under section 5 (including to the 
     extent practicable, patient decision aids for the medical 
     care of the conditions described in section 5(g) and under 
     section 1899 of the Social Security Act, as added by section 
     6.
       (B) Review current training curricula for health care 
     providers on patient decision aids and shared decision making 
     and recommend a training process for eligible providers 
     participating in the pilot program under section 5 on the use 
     of such approved patient decision aids and shared decision 
     making.
       (C) Review existing quality measures regarding patient 
     knowledge, value concordance, and health outcomes that have 
     been endorsed through a consensus-based process and recommend 
     appropriate quality measures for selection under section 
     5(h)(1).
       (3) Appointment.--The expert panel shall be composed of 13 
     members appointed by the Secretary from among leading experts 
     in shared decision making of whom--
       (A) 2 shall be researchers;
       (B) 2 shall be primary care physicians;
       (C) 2 shall be from surgical specialties;
       (D) 2 shall be patient or consumer community advocates;
       (E) 2 shall be nonphysician health care providers (such as 
     nurses, nurse practitioners, and physician assistants);
       (F) 1 shall be from an integrated multispecialty group 
     practice;
       (G) 1 shall be from the National Cancer Institute; and
       (H) 1 shall be from the Centers for Disease Control and 
     Prevention.
       (4) Report.--Not later than 2 years after such date of 
     enactment and each year thereafter until the date of the 
     termination of the expert panel under paragraph (5), the 
     expert panel shall submit to the Secretary a report on the 
     patient decision aids approved under paragraph (2)(A), the 
     training process recommended under paragraph (2)(B), the 
     quality measures recommended under paragraph (2)(C), and 
     recommendations on other conditions or medical care the 
     Secretary may want to include in the pilot program under 
     section 5.
       (5) Termination.--The expert panel shall terminate on such 
     date as the Secretary determines appropriate.
       (c) Quality Measure Development.--

[[Page S5838]]

       (1) In general.--Section 1890(b)(1)(A) of the Social 
     Security Act (42 U.S.C. 1395aaa(b)(1)(A)) is amended--
       (A) in clause (ii), by striking ``and'' at the end; and
       (B) by adding at the end the following new clause:
       ``(iv) that address conditions described in section 5(g) of 
     the Empowering Medicare Patient Choices Act and regional 
     practice variations under this title; and''.
       (2) Conforming amendment.--Section 1890(d) of the Social 
     Security Act (42 U.S.C. 1395aaa(d)) is amended--
       (A) by inserting ``(other than subsection (b)(1)(A)(iv))'' 
     after ``this section''; and
       (B) by adding at the end the following new sentence: ``For 
     provisions relating to funding for the duties described in 
     subsection (b)(1)(A)(iv), see section 5(l) of the Empowering 
     Medicare Patient Choices Act.''.

     SEC. 5. ESTABLISHMENT OF SHARED DECISION MAKING PILOT PROGRAM 
                   UNDER THE MEDICARE PROGRAM.

       (a) In General.--Not later than 12 months after the date of 
     enactment of this Act, the Secretary shall establish a pilot 
     program to provide for the phased-in development, 
     implementation, and evaluation of shared decision making 
     under the Medicare program using patient decision aids to 
     meet the objective of improving the understanding by Medicare 
     beneficiaries of their medical treatment options, as compared 
     to comparable Medicare beneficiaries who do not participate 
     in a shared decision making process using patient decision 
     aids.
       (b) Initial Implementation (Phase I).--
       (1) In general.--During the initial implementation of the 
     pilot program under this section (referred to in this section 
     as ``Phase I'' of the pilot program), the Secretary shall 
     enroll in the pilot program not more than 15 eligible 
     providers who have experience in implementing, and have 
     invested in the necessary infrastructure to implement, shared 
     decision making using patient decision aids for a period of 3 
     years.
       (2) Application.--An eligible provider seeking to 
     participate in the pilot program during phase I shall submit 
     to the Secretary an application at such time and containing 
     such information as the Secretary may require.
       (3) Preference.--In enrolling eligible providers in the 
     pilot program during phase I, the Secretary shall give 
     preference to eligible providers that--
       (A) have documented experience in using patient decision 
     aids for the conditions identified in subsection (g) and in 
     using shared decision making;
       (B) have the necessary information technology 
     infrastructure to collect the information required by the 
     Secretary for reporting purposes;
       (C) are trained in how to use patient decision aids and 
     shared decision making; and
       (D) would be eligible to receive financial assistance as a 
     Shared Decision Making Resource Center under subsection (c).
       (c) Shared Decision Making Resource Centers.--
       (1) In general.--The Secretary shall provide financial 
     assistance for the establishment and support of Shared 
     Decision Making Resource Centers (referred to in this section 
     as ``centers'') to provide technical assistance to eligible 
     providers and to develop and disseminate best practices and 
     other information to support and accelerate adoption, 
     implementation, and effective use of patient decision aids 
     and shared decision making by eligible providers under the 
     Medicare program.
       (2) Affiliation.--Centers shall be affiliated with a United 
     States-based organization or group that applies for and is 
     awarded financial assistance under this subsection. The 
     Secretary shall provide financial assistance to centers under 
     this subsection on the basis of merit.
       (3) Objectives.--The objective of a center is to enhance 
     and promote the adoption of patient decision aids and shared 
     decision making through--
       (A) providing assistance to eligible providers with the 
     implementation and effective use of, and training on, patient 
     decision aids;
       (B) the dissemination of best practices and research on the 
     implementation and effective use of patient decision aids; 
     and
       (C) providing assistance to eligible providers applying to 
     participate or participating in phase II of the pilot program 
     under this section or under section 1899 of the Social 
     Security Act, as added by section 6.
       (4) Regional assistance.--Each center shall aim to provide 
     assistance and education to all eligible providers in a 
     region, including direct assistance to the following eligible 
     providers:
       (A) Public or not-for-profit hospitals or critical access 
     hospitals (as defined in section 1861 (mm)(1) of the Social 
     Security Act (42 U.S.C. 1395x(mm)(1)).
       (B) Federally qualified health centers (as defined in 
     section 1861(aa)(4) of the Social Security Act (42 U.S.C. 
     1395x(aa)(4)).
       (C) Entities that are located in a rural area or in area 
     that serves uninsured, underinsured, and medically 
     underserved individuals (regardless of whether such area is 
     urban or rural).
       (D) Individual or small group practices (or a consortium 
     thereof) that are primarily focused on primary care.
       (5) Financial assistance.--
       (A) In general.--The Secretary may provide financial 
     assistance for a period of 8 years to any regional center 
     established or supported under this subsection.
       (B) Cost-sharing requirement.--
       (i) In general.--Except as provided in clause (ii), the 
     Secretary shall not provide as financial assistance under 
     this subsection more than 50 percent of the capital and 
     annual operating and maintenance funds required to establish 
     and support such a center.
       (ii) Waiver of cost-sharing requirement.--The Secretary may 
     waive the limitation under clause (i) if the Secretary 
     determines that, as a result of national economic conditions, 
     such limitation would be detrimental to the pilot program 
     under this section. If the Secretary waives such limitation 
     under the preceding sentence, the Secretary shall submit to 
     Congress a report containing the Secretary's justification 
     for such waiver.
       (6) Notice of program description and availability of 
     funds.--The Secretary shall publish in the Federal Register, 
     not later than 12 months after the date of the enactment of 
     this Act, a draft description of a program for establishing 
     and supporting regional centers under this subsection. Such 
     draft description shall include the following:
       (A) A detailed explanation of the program and the program 
     goals.
       (B) Procedures to be followed by applicants for financial 
     assistance.
       (C) Criteria for determining which applicants are qualified 
     to receive financial assistance.
       (D) Maximum support levels expected to be available to 
     centers under the program.
       (7) Application review.--The Secretary shall review each 
     application for financial assistance under this subsection 
     based on merit. In making a decision whether to approve such 
     application and provide financial assistance, the Secretary 
     shall consider at a minimum the merits of the application, 
     including those portions of the application regarding--
       (A) the ability of the applicant to provide assistance to 
     particular categories of eligible providers with respect to 
     the implementation and effective use of, and training on, 
     patient decision aids;
       (B) the geographical diversity and extent of the service 
     area of the applicant; and
       (C) the percentage of funding for the center that would be 
     provided as financial assistance under this subsection and 
     the amount of any funding or in-kind commitment from sources 
     of funding in addition to the financial assistance provided 
     under this subsection.
       (8) Biennial evaluation.--Each center which receives 
     financial assistance under this subsection shall be evaluated 
     biennially by an evaluation panel appointed by the Secretary. 
     Each such evaluation panel shall be composed of private 
     experts, none of whom shall be connected with the center 
     involved, and officials of the Federal Government. Each 
     evaluation panel shall measure the performance of the center 
     involved against the objectives specified in paragraph (3). 
     The Secretary shall not continue to provide financial 
     assistance to a center under this subsection unless the most 
     recent evaluation under this paragraph with respect to the 
     center is overall positive.
       (d) Expanded Implementation (phase II).--
       (1) In general.--Subject to paragraph (2), during the 3-
     year period beginning after the completion of phase I of the 
     pilot program (referred to in this section as ``phase II'' of 
     the pilot program), the Secretary shall enroll additional 
     eligible providers to implement shared decision making using 
     patient decision aids under the pilot program under this 
     section. The Secretary may allow eligible providers to enroll 
     in the pilot program on a regular basis during phase II.
       (2) Contingency.--The Secretary shall not implement phase 
     II of the pilot program if the Secretary finds, not later 
     than 90 days after the date of submittal of the interim 
     report under subsection (i)(2)(A), that the continued 
     implementation of shared decision making is not in the best 
     interest of Medicare beneficiaries.
       (3) Preference.--In enrolling eligible providers in the 
     pilot program during phase II, the Secretary shall include, 
     to the extent practicable, eligible providers that--
       (A) have or can acquire the infrastructure necessary to 
     implement shared decision making supported by patient 
     decision aids approved by the expert panel established under 
     section 4(b) in a timely manner;
       (B) have training in the use of patient decision aids or 
     will participate in training for health care professionals 
     who will be involved in such use (as specified by the 
     Secretary); or
       (C) represent high cost areas or high practice variation 
     States under the Medicare program, and the District of 
     Columbia.
       (e) Guidance.--The Secretary may, in consultation with the 
     expert panel established under section 4(b), issue guidance 
     to eligible providers participating in the pilot program 
     under this section on the use of patient decision aids 
     approved by the expert panel.
       (f) Requirements.--
       (1) Implementation of approved patient decision aids.--
       (A) In general.--During phase II of the pilot program under 
     this section, an eligible provider participating in the pilot 
     program shall incorporate 1 or more patient decision aids 
     approved by the expert panel established under section 4(b) 
     in furnishing items and services to Medicare beneficiaries 
     with respect to 1 or more of the conditions identified in 
     subsection (g), together with ongoing support involved in 
     furnishing such items and services.

[[Page S5839]]

       (B) Defined clinical process.--During each phase of the 
     pilot program under this section, the eligible provider shall 
     establish and implement a defined clinical process under 
     which, in the case of a Medicare beneficiary with 1 or more 
     of such conditions, the eligible provider offers the Medicare 
     beneficiary shared decision making (supported by such a 
     patient decision aid) and collects information on the quality 
     of patient decision making with respect to the Medicare 
     beneficiary.
       (2) Follow-up counseling visit.--
       (A) In general.--During each phase of the pilot program 
     under this section, an eligible provider participating in the 
     pilot program under this section shall routinely schedule 
     Medicare beneficiaries for a counseling visit after the 
     viewing of such a patient decision aid to answer any 
     questions the beneficiary may have with respect to the 
     medical care of the condition involved and to assist the 
     beneficiary in thinking through how their preferences and 
     concerns relate to their medical care.
       (B) Payment for follow-up counseling visit.--The Secretary 
     shall establish procedures for making payments for such 
     counseling visits provided to Medicare beneficiaries during 
     each phase of the pilot program under this section. Such 
     procedures shall provide for the establishment--
       (i) of a code (or codes) to represent such services; and
       (ii) of a single payment amount for such service that 
     includes the professional time of the health care provider 
     and a portion of the reasonable costs of the infrastructure 
     of the eligible provider.
       (C) Limitation.--In the case of an eligible provider that 
     is a Medicare Advantage plan, such eligible provider may not 
     receive payment for such services.
       (3) Waiver of coinsurance.--The Secretary shall establish 
     procedures under which an eligible provider participating in 
     the pilot program under this section may, in the case of a 
     low-income Medicare beneficiary (as determined by the 
     Secretary), waive any coinsurance or copayment that would 
     otherwise apply for the follow-up counseling visit provided 
     to such Medicare beneficiary under paragraph (2).
       (4) Costs of implementation.--
       (A) In general.--Subject to subparagraph (B), during each 
     phase of the pilot program, an eligible provider 
     participating in the pilot program shall be responsible for 
     the costs of selecting, purchasing, and incorporating such 
     patient decision aids into the group practice, reporting data 
     on quality measures selected under subsection (h)(1), and 
     recording outcomes under the pilot program.
       (B) Financial support.--During each such phase, the 
     Secretary may, in addition to payments for counseling visits 
     under paragraph (2), provide financial support to an eligible 
     provider participating in the pilot program to acquire the 
     infrastructure necessary to participate in the pilot program, 
     including the development of clinical pathways to assure that 
     Medicare beneficiaries have access to high-quality shared 
     decision making, the reporting of data on quality measures 
     selected under subsection (h)(1), and the recording of 
     outcomes under the pilot program after phase I of the pilot 
     program (as determined appropriate by the Secretary).
       (g) Preference Sensitive Care Described.--The patient 
     decision aids approved under section 4(b)(2)(A) shall, to the 
     extent practicable, include patient decision aids for medical 
     care of the following conditions:
       (1) Arthritis of the hip and knee.
       (2) Chronic back pain.
       (3) Chest pain (stable angina).
       (4) Enlarged prostate (benign prostatic hypertrophy, or 
     BPH).
       (5) Early-stage prostate cancer.
       (6) Early-stage breast cancer.
       (7) End-of-life care.
       (8) Peripheral vascular disease.
       (9) Gall stones.
       (10) Threat of stroke from carotid artery disease.
       (11) Any other condition the Secretary identifies as 
     appropriate.
       (h) Quality Measures.--
       (1) Selection.--
       (A) In general.--During each phase of the pilot program, 
     the Secretary shall measure the quality and implementation of 
     shared decision making. For purposes of making such 
     measurements, the Secretary shall select, from among those 
     quality measures recommended by the expert panel under 
     section 4(b)(2)(C), consensus-based quality measures that 
     assess Medicare beneficiaries' knowledge of the options for 
     medical treatment relevant to their medical condition, as 
     well as the benefits and drawbacks of those medical treatment 
     options, and the Medicare beneficiaries' goals and concerns 
     regarding their medical care.
       (B) Risk adjustment.--In order to ensure accurate 
     measurement across quality measures and eligible providers, 
     the Secretary may risk adjust the quality measures selected 
     under this paragraph to control for external factors, such as 
     cognitive impairment, dementia, and literacy.
       (2) Reporting data on measures.--During each such phase, an 
     eligible provider participating in the pilot program shall 
     report to the Secretary data on quality measures selected 
     under paragraph (1) in accordance with procedures established 
     by the Secretary.
       (3) Feedback on measures.--During each such phase, the 
     Secretary shall provide confidential reports to eligible 
     providers participating in the pilot program on the 
     performance of the eligible provider on quality measures 
     selected by the Secretary under paragraph (1), the aggregate 
     performance of all eligible providers participating in the 
     pilot program, and any improvements in such performance.
       (i) Evaluations and Reports.--
       (1) Independent evaluation.--The Secretary shall enter into 
     a contract with an entity that has knowledge of shared 
     decision making programs and demonstrated experience in the 
     evaluation of such programs for the conduct of an independent 
     evaluation of each phase of the pilot program under this 
     section.
       (2) Reports by entity conducting independent evaluation.--
       (A) Interim report.--Not later than 2 years after the 
     implementation of phase I of the pilot program, the entity 
     with a contract under paragraph (1) shall submit to the 
     Secretary a report on the initial results of the independent 
     evaluation conducted under such paragraph.
       (B) Final report.--Not later then 4 years after the 
     implementation of phase II of the pilot program, such entity 
     shall submit to the Secretary a report on the final results 
     of such independent evaluation.
       (C) Contents of report.--Each report submitted under this 
     paragraph shall--
       (i) include an assessment of--

       (I) quality measures selected under subsection (h)(1);
       (II) Medicare beneficiary and health care provider 
     satisfaction under the applicable phase of the pilot program;
       (III) utilization of medical services for Medicare 
     beneficiaries with 1 or more of the conditions described in 
     subsection (g) and other Medicare beneficiaries as determined 
     appropriate by the Secretary;
       (IV) appropriate utilization of shared decision making by 
     eligible providers under the applicable phase of the pilot 
     program;
       (V) savings to the Medicare program under title XVIII of 
     the Social Security Act; and
       (VI) the costs to eligible providers participating in the 
     pilot program of selecting, purchasing, and incorporating 
     approved patient decision aids and meeting reporting 
     requirements under the applicable phase of the pilot program; 
     and

       (ii) identify the characteristics of individual eligible 
     providers that are most effective in implementing shared 
     decision making under the applicable phase of the pilot 
     program.
       (3) Report by the secretary.--Not later than 12 months 
     after the completion of phase II of the pilot program, the 
     Secretary shall submit to Congress a report on the pilot 
     program that includes--
       (A) the results of the independent evaluation conducted 
     under paragraph (2);
       (B) an evaluation of the impact of the pilot program under 
     this section, including the impact--
       (i) of the use of patient decision aids approved by the 
     expert panel established under section 4(b) for the medical 
     care of the conditions described in subsection (g);
       (ii) on expenditures for such conditions under the Medicare 
     program, including a comparison of such expenditures for such 
     conditions where such patient decision aids were used to such 
     expenditures for such conditions where such patient decision 
     aids were not used; and
       (iii) on Medicare beneficiaries, including the 
     understanding by beneficiaries of the options for medical 
     care presented, concordance between beneficiary values and 
     the medical care received, the mode of approved patient 
     decision aid used (such as Internet, videos, and pamphlets), 
     the timing of the delivery of such approved patient decision 
     aid (such as the date of the initial diagnosis), and 
     beneficiary and health care provider satisfaction with the 
     shared decision making process;
       (C) an evaluation of which eligible providers are most 
     effective at implementing patient decision aids and assisting 
     Medicare beneficiaries in making informed decisions on 
     medical care; and
       (D) recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.
       (j) Savings.--
       (1) In general.--Subject to paragraph (2), not later than 2 
     years after the implementation of phase I of the pilot 
     program, and annually thereafter for the duration of phase I 
     and the first 2 years of phase II, the Secretary shall 
     determine if there were any savings to the Medicare program 
     as a result of such implementation during the preceding year 
     (or years, if applicable). In the case where the Secretary 
     determines there were such savings, the Secretary shall use 
     such savings as follows:
       (A) Fifty percent of such savings shall be used to provide 
     bonus payments to eligible providers participating in the 
     pilot program who achieve high quality shared decision making 
     (as measured by the level of participation of Medicare 
     beneficiaries in the shared decision making process and high 
     scores by the eligible provider on quality measures selected 
     under subsection (h)(1)).
       (B) Twenty-five percent of such savings shall be placed in 
     a Shared Decision Making Trust Fund established by the 
     Secretary, which shall be used to expand participation in the 
     pilot program to providers of services and suppliers in 
     additional settings (as determined appropriate by the 
     Secretary) by--
       (i) providing financial assistance under subsection (c); 
     and

[[Page S5840]]

       (ii) providing for the development of quality measures not 
     already selected under subsection (h)(1) to assess the impact 
     of shared decision making on the quality of patient care or 
     the improvement of such quality measures already selected.
       (C) Twenty-five percent of such savings shall be retained 
     by the Medicare program.
       (2) Retention of savings by the medicare program.--In the 
     case where the Secretary determines there are savings to the 
     Medicare program as a result of the implementation of the 
     pilot program during a year (beginning with the third year of 
     phase II), 100 percent of such savings shall be retained by 
     the Medicare program.
       (k) Waiver.--The Secretary may waive such provisions of 
     titles XI and XVIII of the Social Security Act as may be 
     necessary to carry out the pilot program under this section.
       (l) Funding.--For purposes of carrying out section 4(a), 
     implementing the pilot program under this section (including 
     costs incurred in conducting the evaluation under subsection 
     (i)), and carrying out section 1890(b)(1)(A)(iv) of the 
     Social Security Act, as added by section 4(c), the Secretary 
     shall provide for the transfer from the Federal Hospital 
     Insurance Trust Fund established under section 1817 of the 
     Social Security Act (42 U.S.C. 1395i) to the Centers for 
     Medicare & Medicaid Services Program Management Account of 
     $300,000,000 for the period of fiscal years 2010 through 
     2017.

     SEC. 6. ESTABLISHMENT OF SHARED DECISION MAKING STANDARDS AND 
                   REQUIREMENTS IN MEDICARE.

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


  ``establishment of shared decision making standards and requirements

       ``Sec. 1899.  (a) In General.--Based on the findings of 
     phases I and II of the pilot program under section 5 of the 
     Empowering Medicare Patient Choices Act the Secretary shall 
     promulgate regulations that--
       ``(1) specify for which preference sensitive conditions 
     beneficiaries should, subject to the succeeding provisions of 
     this section, participate in shared decision making;
       ``(2) require providers of services and suppliers to make 
     sure that beneficiaries receive patient decision aids as 
     appropriate; and
       ``(3) specify a process for beneficiaries to elect not to 
     use such patient decision aids.
       ``(b) Penalty for Not Using Shared Decision Making.--
     Notwithstanding any other provision of this title, the 
     Secretary shall promulgate such regulations and issue such 
     guidance as may be necessary to reduce by 20 percent the 
     amount of payment under this title that would otherwise apply 
     to an item or service specified by the Secretary if the 
     patient does not receive a patient decision aid prior to such 
     item or service being furnished (except in the case where the 
     beneficiary has elected not to use such patient decision aid 
     under the process specified under subsection (a)(3)).
       ``(c) Secretarial Authority to Waive Application of This 
     Section.--The Secretary may waive the application of this 
     section to an item or service under this title if the 
     Secretary determines either of the following:
       ``(1) Medical societies and others have established 
     evidence-based transparent standards incorporating patient 
     decision aids and shared decision making into the standard of 
     patient care for preference sensitive conditions.
       ``(2) Shared decision making is not in the best interest of 
     beneficiaries.''.
                                 ______
                                 
      By Mr. CASEY:
  SA 1134. A bill to ensure the energy independence and economic 
viability of the Untied States by promoting the responsible use of coal 
through accelerated carbon capture and storage and through advanced 
clean coal technology research, development, demonstration, and 
deployment programs, and for other purposes; to the Committee on Energy 
and Natural Resources.
  Mr. CASEY. Mr. President, I rise today to introduce the Responsible 
Use of Coal Act of 2009. This bill provides the Department of Energy 
with the funding needed to continue to accelerate both the research and 
development and the demonstration, and ultimately, the deployment of 
carbon capture and storage, CCS, technology. Further, this bill would 
position the U.S. as the world leader in CCS technology development and 
export, creating the potential for thousands of new clean energy jobs.
  Climate change is one of the most complex and challenging imperatives 
that our Nation, and, the world, has ever faced. We need to move 
forward in crafting a national program that will reduce our greenhouse 
gas emissions, encourage the use of renewable power, and create clean 
energy jobs. As we move forward, we must do so in a manner that will 
ensure our energy security, protect our industries from ``carbon 
leakage,'' help get our economy back on track, and enable us to 
continue to benefit from our most abundant, affordable energy 
resource--coal.
  Today coal provides over half of the Nation's electricity. While coal 
use for energy generation has more than tripled since 1970, emissions 
of sulfur dioxide, nitrogen oxide, and particulate matter from power 
plants have been dramatically reduced as the power industry deploys 
technologies for capturing these pollutants. Now, responding to health 
concerns about mercury, power plants are implementing technology to 
capture this toxic element. This illustrates how the development and 
deployment of advanced technology has allowed coal to continue to play 
such an important role in our energy strategy in the face of strict 
environmental requirements.
  Coal helps keep American homes, businesses, factories, airports, 
schools and hospitals humming. Coal creates millions of good-paying 
jobs across all sectors of the economy--from direct and indirect mining 
and electric utility jobs to all those businesses and industries, large 
and small, which depend on affordable electricity to compete in the 
global marketplace. Coal-based electricity keeps people warm on 
freezing nights and comfortable during the hottest of summer days. Coal 
provides the reliable, secure electricity needed for the myriad of 
medical procedures to detect and treat cancer, heart disease and other 
health threats, saving innumerous lives every year. Electricity from 
coal is there when you need it.
  Much of the world depends on coal, and developing economies like 
China and India are increasingly relying on coal to power them into the 
21st Century. Coal supplies more than 40 percent of worldwide 
electricity demand. For China, the amount of electricity from coal is 
astonishing. Eighty percent of China's electricity comes from coal. 
Prior to the current global recession, China built one to two new coal 
plants every week.
  But the continued use of coal in the U.S. and abroad has a 
significant challenge ahead of it--climate change. While we have made 
progress in the U.S. in dealing with climate change, we are still at 
the beginning of the process of piecing together a domestic program 
that will work for all of the different regions of this country and 
that will reduce our greenhouse gas emissions so that we meet our 
global commitment.
  One of the key pieces that must be included in our domestic program 
to help meet the challenge of climate change is carbon capture and 
storage. I am sponsoring the Responsible Use of Coal Act of 2009 to 
supplement funding under the American Recovery and Reinvestment Act by 
further accelerating the Department of Energy's CCS research, 
development, demonstration, and deployment programs. Specifically the 
bill will promote the rapid commercial demonstration and early 
deployment of carbon capture and storage systems that will allow the 
Nation to continue to use its abundant, secure, and low-cost coal 
resources while moving forward with a national program to reduce the 
impact of man-made emissions on our environment.
  The bill will promote the continued research and development of 
advanced CCS and other coal power generation technologies in order to 
drive down costs, increase performance, and foster innovation. It is 
crucial that, in parallel to the commercial demonstration of current 
CCS technology, we continue to develop and advance new CCS ideas and 
concepts through a robust research and development program in order to 
continue to lower the cost of complying with CO2 
regulations.
  The bill will promote the export of U.S. CCS technologies to those 
countries, such as China and India, which also rely on coal as their 
dominant energy source--ensuring that the U.S. is the leader in 
developing and exporting clean coal technologies and taking advantage 
of the thousands of new clean energy jobs such an industry would 
create.
  I am fully committed to work with my colleagues in the Senate in 
addressing climate change. At the same time, I believe that the Nation 
needs to recognize the critical role coal plays in driving our economic 
engine and to aggressively move forward in the research, development, 
demonstration, and deployment of CCS technology.
  I urge all of my colleagues to join me in ensuring that the United 
States continues to enjoy the economic and energy security advantages 
that our domestic coal resources afford us while we move forward in 
crafting legislation

[[Page S5841]]

that will reduce our emissions of greenhouse gases.
  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. 1134

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Responsible Use of Coal Act 
     of 2009''.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Carbon capture and storage technology.--The term 
     ``carbon capture and storage technology'' means an advanced 
     technology or concept that the Secretary determines to have 
     the potential--
       (A) to capture or remove--
       (i) carbon dioxide that is emitted from a coal-fired power 
     plant; and
       (ii) other industrial sources;
       (B) to store carbon dioxide in geological formations; and
       (C) to use carbon dioxide for--
       (i) enhanced oil and natural gas recovery; or
       (ii) other large-volume, beneficial uses.
       (2) Carbon capture technology.--
       (A) In general.--The term ``carbon capture technology'' 
     means any precombustion technology, post-combustion 
     technology, or oxy-combustion technology or process.
       (B) Inclusion.--The term ``carbon capture technology'' 
     includes carbon dioxide compression technology.
       (3) Enhanced oil and natural gas recovery.--The term 
     ``enhanced oil and natural gas recovery'' means the use of 
     carbon dioxide to improve or enhance the recovery of oil or 
     natural gas from a depleted oil or natural gas field.
       (4) Precombustion technology.--The term ``precombustion 
     technology'' means a coal or coal-biomass gasification or 
     integrated gasification combined-cycle process coupled with 
     carbon dioxide storage or reuse.
       (5) Secretary.--The term ``Secretary'' means the Secretary 
     of Energy.

     SEC. 3. PURPOSES.

       The purposes of this Act are--
       (1) to promote the continued responsible use of the 
     abundant, secure, and low-cost coal resources of the United 
     States through the research, development, demonstration, and 
     deployment of--
       (A) carbon capture and storage technologies; and
       (B) advanced coal power generation technologies;
       (2) to promote the exportation of the carbon capture and 
     storage technologies and advanced coal power generation 
     technologies developed by the United States to countries that 
     rely on coal as the dominant energy source of the countries 
     (including China and India); and
       (3) to support the deployment of carbon capture and storage 
     technologies by--
       (A) quantifying the risks of the technologies; and
       (B) helping to establish the most appropriate framework for 
     managing liabilities associated with all phases of carbon 
     capture and storage technology projects, including--
       (i) the capture and transportation of carbon dioxide; and
       (ii) the siting, design, operation, closure, and long-term 
     stewardship of carbon dioxide storage facilities.

     SEC. 4. PROGRAMS.

       (a) Research and Development Program.--
       (1) In general.--As soon as practicable after the date of 
     enactment of this Act, in accordance with paragraph (2) and 
     subsection (b), the Secretary, acting through the Director of 
     the National Energy Technology Laboratory, shall carry out a 
     research, development, and demonstration program through the 
     National Energy Technology Laboratory to further advance 
     carbon capture and storage and coal power generation 
     technologies.
       (2) Required programs.--The program described in paragraph 
     (1) shall include each program described in paragraphs (3) 
     through (6).
       (3) Commercial demonstration program.--As soon as 
     practicable after the date of enactment of this Act, the 
     Secretary, acting through the Director of the National Energy 
     Technology Laboratory, shall carry out a large-scale 
     commercial demonstration program to evaluate the most 
     promising carbon capture and storage technologies.
       (4) Research and development program regarding carbon 
     capture technologies.--As soon as practicable after the date 
     of enactment of this Act, the Secretary shall carry out a 
     research and development program under which the Secretary 
     shall evaluate carbon capture technologies to decrease the 
     cost, and increase the performance, of carbon capture 
     technologies.
       (5) Research and development program regarding carbon 
     dioxide storage.--As soon as practicable after the date of 
     enactment of this Act, the Secretary shall carry out a 
     research and development program under which the Secretary 
     shall evaluate options for carbon dioxide storage in 
     geological formations--
       (A) for enhanced oil and natural gas recovery; and
       (B) to decrease the cost, and increase the performance, of 
     carbon capture and storage technologies in existence as of 
     the date of enactment of this Act.
       (6) Research and development program regarding advanced 
     clean coal power generation technologies.--As soon as 
     practicable after the date of enactment of this Act, the 
     Secretary shall carry out a research and development program 
     under which the Secretary shall evaluate advanced clean coal 
     power generation technologies to make practicable--
       (A) the capture and storage of carbon dioxide; and
       (B) highly efficient power generation (including advanced 
     turbines, fuel cells, hydrogen production, and advanced 
     gasification).
       (b) Cost-Sharing Requirements.--
       (1) Commercial demonstration program.--The Federal share of 
     the cost of any competitively procured project carried out 
     using funds provided under the commercial demonstration 
     program described in subsection (a)(3) shall be not more than 
     50 percent.
       (2) Other programs.--The Federal share of the cost of any 
     competitively procured project carried out using funds 
     provided under a program described in paragraph (4), (5), or 
     (6) of subsection (a) shall be not more than 80 percent.

     SEC. 5. AUTHORIZATION OF APPROPRIATIONS.

       There are authorized to be appropriated to the Secretary--
       (1) to carry out the commercial demonstration program under 
     section 4(a)(3)--
       (A) $300,000,000 for fiscal year 2010;
       (B) $350,000,000 for fiscal year 2011;
       (C) $400,000,000 for fiscal year 2012; and
       (D) $400,000,000 for fiscal year 2013;
       (2) to carry out the research and development program under 
     section 4(a)(4)--
       (A) $80,000,000 for fiscal year 2010;
       (B) $100,000,000 for fiscal year 2011;
       (C) $120,000,000 for fiscal year 2012; and
       (D) $120,000,000 for fiscal year 2013;
       (3) to carry out the research and development program under 
     section 4(a)(5)--
       (A) $170,000,000 for fiscal year 2010;
       (B) $200,000,000 for fiscal year 2011;
       (C) $225,000,000 for fiscal year 2012; and
       (D) $225,000,000 for fiscal year 2013; and
       (4) to carry out the research and development program under 
     section 4(a)(6)--
       (A) $250,000,000 for fiscal year 2010;
       (B) $270,000,000 for fiscal year 2011;
       (C) $300,000,000 for fiscal year 2012; and
       (D) $300,000,000 for fiscal year 2013.
                                 ______
                                 
      By Ms. STABENOW (for herself, Mr. Brownback, Mr. Durbin, Mr. 
        Voinovich, Mr. Levin, Mr. Brown, Ms. Mikulski, and Mr. 
        Lieberman):
  S. 1135. A bill to establish a voluntary program in the National 
Highway Traffic Safety Administration to encourage consumers to trade-
in older vehicles for more fuel efficient vehicles, and for other 
purposes; to the Committee on Commerce, Science, and Transportation.
  Ms. STABENOW. 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. 1135

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Drive America Forward Act of 
     2009''.

     SEC. 2. DRIVE AMERICA FORWARD PROGRAM.

       (a) Establishment.--There is established in the National 
     Highway Traffic Safety Administration a voluntary program to 
     be known as the ``Drive America Forward Program'' through 
     which the Secretary, in accordance with this section and the 
     regulations promulgated under subsection (d), shall--
       (1) authorize the issuance of an electronic voucher, 
     subject to the specifications set forth in subsection (c), to 
     offset the purchase price or lease price for a qualifying 
     lease of a new fuel efficient automobile upon the surrender 
     of an eligible trade-in vehicle to a dealer participating in 
     the Program;
       (2) certify dealers for participation in the Program--
       (A) to accept vouchers as provided in this section as 
     partial payment or down payment for the purchase or 
     qualifying lease of any new fuel efficient automobile offered 
     for sale or lease by that dealer; and
       (B) in accordance with subsection (c)(2), to transfer each 
     eligible trade-in vehicle surrendered to the dealer under the 
     Program to an entity for disposal;
       (3) in consultation with the Secretary of the Treasury, 
     make electronic payments to dealers for vouchers accepted by 
     such dealers, in accordance with the regulations issued under 
     subsection (d);
       (4) in consultation with the Secretary of the Treasury, 
     provide for the payment of rebates to persons who qualify for 
     a rebate under subsection (c)(3); and
       (5) in consultation with the Secretary of the Treasury and 
     the Inspector General of the Department of Transportation, 
     establish and provide for the enforcement of measures to 
     prevent and penalize fraud under the Program.

[[Page S5842]]

       (b) Qualifications for and Value of Vouchers.--A voucher 
     issued under the Program shall have a value that may be 
     applied to offset the purchase price or lease price for a 
     qualifying lease of a new fuel efficient automobile as 
     follows:
       (1) $3,500 value.--The voucher may be used to offset the 
     purchase price or lease price of the new fuel efficient 
     automobile by $3,500 if--
       (A) the new fuel efficient automobile is a passenger 
     automobile and the combined fuel economy value of such 
     automobile is at least 4 miles per gallon higher than the 
     combined fuel economy value of the eligible trade-in vehicle;
       (B) the new fuel efficient automobile is a category 1 truck 
     and the combined fuel economy value of such truck is at least 
     2 miles per gallon higher than the combined fuel economy 
     value of the eligible trade-in vehicle;
       (C) the new fuel efficient automobile is a category 2 truck 
     that has a combined fuel economy value of at least 15 miles 
     per gallon and--
       (i) the eligible trade-in vehicle is a category 2 truck and 
     the combined fuel economy value of the new fuel efficient 
     automobile is at least 1 mile per gallon higher than the 
     combined fuel economy value of the eligible trade-in vehicle; 
     or
       (ii) the eligible trade-in vehicle is a category 3 truck of 
     model year 2001 or earlier; or
       (D) the new fuel efficient automobile is a category 3 truck 
     and the eligible trade-in vehicle is a category 3 truck of 
     model year of 2001 or earlier and is of similar size or 
     larger than the new fuel efficient automobile as determined 
     in a manner prescribed by the Secretary.
       (2) $4,500 value.--The voucher may be used to offset the 
     purchase price or lease price of the new fuel efficient 
     automobile by $4,500 if--
       (A) the new fuel efficient automobile is a passenger 
     automobile and the combined fuel economy value of such 
     automobile is at least 10 miles per gallon higher than the 
     combined fuel economy value of the eligible trade-in vehicle;
       (B) the new fuel efficient automobile is a category 1 truck 
     and the combined fuel economy value of such truck is at least 
     5 miles per gallon higher than the combined fuel economy 
     value of the eligible trade-in vehicle; or
       (C) the new fuel efficient automobile is a category 2 truck 
     that has a combined fuel economy value of at least 15 miles 
     per gallon and the combined fuel economy value of such truck 
     is 2 miles per gallon higher than the combined fuel economy 
     value of the eligible trade-in vehicle and the eligible 
     trade-in vehicle is a category 2 truck.
       (c) Program Specifications.--
       (1) Limitations.--
       (A) General period of eligibility.--A voucher issued under 
     the Program shall be used only for the purchase or qualifying 
     lease of new fuel efficient automobiles that occur between--
       (i) March 30, 2009; and
       (ii) the day that is 1 year after the date on which the 
     regulations promulgated under subsection (d) are implemented.
       (B) Number of vouchers per person and per trade-in 
     vehicle.--Not more than 1 voucher may be issued for a single 
     person and not more than 1 voucher may be issued for the 
     joint registered owners of a single eligible trade-in 
     vehicle.
       (C) No combination of vouchers.--Only 1 voucher issued 
     under the Program may be applied toward the purchase or 
     qualifying lease of a single new fuel efficient automobile.
       (D) Cap on funds for category 3 trucks.--Not more than 7.5 
     percent of the total funds made available for the Program 
     shall be used for vouchers for the purchase or qualifying 
     lease of category 3 trucks.
       (E) Combination with other incentives permitted.--The 
     availability or use of a Federal, State, or local incentive 
     or a State-issued voucher for the purchase or lease of a new 
     fuel efficient automobile shall not limit the value or 
     issuance of a voucher under the Program to any person 
     otherwise eligible to receive such a voucher.
       (F) No additional fees.--A dealer participating in the 
     program may not charge a person purchasing or leasing a new 
     fuel efficient automobile any additional fees associated with 
     the use of a voucher under the Program.
       (G) Number and amount.--The total number and value of 
     vouchers issued under the Program may not exceed the amounts 
     appropriated for such purpose.
       (2) Disposition of eligible trade-in vehicles.--
       (A) In general.--For each eligible trade-in vehicle 
     surrendered to a dealer under the Program, the dealer shall 
     certify to the Secretary, in such manner as the Secretary 
     shall prescribe by rule, that the dealer--
       (i) has not and will not sell, lease, exchange, or 
     otherwise dispose of the vehicle for use as an automobile in 
     the United States or in any other country; and
       (ii) will transfer the vehicle (including the engine and 
     drive train), in such manner as the Secretary prescribes, to 
     an entity that will ensure that the vehicle--

       (I) will be crushed or shredded within such period and in 
     such manner as the Secretary prescribes; and
       (II) has not been, and will not be, sold, leased, 
     exchanged, or otherwise disposed of for use as an automobile 
     in the United States or in any other country.

       (B) Savings provision.--Nothing in subparagraph (A) may be 
     construed to preclude a person who dismantles or disposes of 
     the vehicle from--
       (i) selling any parts of the disposed vehicle other than 
     the engine block and drive train (unless the engine or drive 
     train has been crushed or shredded); or
       (ii) retaining the proceeds from such sale.
       (C) Coordination.--The Secretary shall coordinate with the 
     Attorney General to ensure that the National Motor Vehicle 
     Title Information System and other publicly accessible 
     systems are appropriately updated on a timely basis to 
     reflect the crushing or shredding of vehicles under this 
     section and appropriate reclassification of the vehicles' 
     titles. The commercial market shall also have electronic and 
     commercial access to the vehicle identification numbers of 
     vehicles that have been disposed of on a timely basis.
       (3) Eligible purchases or leases prior to date of 
     enactment.--A person who purchased or leased a new fuel 
     efficient vehicle after March 30, 2009, and before the date 
     of the enactment of this Act is eligible for a cash rebate 
     equivalent to the amount described in subsection (b)(1) if 
     the person provides proof satisfactory to the Secretary 
     that--
       (A)(i) the person was the registered owner of an eligible 
     trade-in vehicle; or
       (ii) if the person leased the vehicle, the lease was a 
     qualifying lease; and
       (B) the vehicle has been disposed of in accordance with 
     clauses (i) and (ii) of paragraph (2)(A).
       (d) Regulations.--Notwithstanding the requirements of 
     section 553 of title 5, United States Code, the Secretary 
     shall promulgate final regulations to implement the Program 
     not later than 30 days after the date of the enactment of 
     this Act. Such regulations shall--
       (1) provide for a means of certifying dealers for 
     participation in the Program;
       (2) establish procedures for the reimbursement of dealers 
     participating in the Program to be made through electronic 
     transfer of funds for both the amount of the vouchers and any 
     reasonable administrative costs incurred by the dealer as 
     soon as practicable but no longer than 10 days after the 
     submission of a voucher for the new fuel efficient automobile 
     to the Secretary;
       (3) allow the dealer to use the voucher in addition to any 
     other rebate or discount offered by the dealer or the 
     manufacturer for the new fuel efficient automobile and 
     prohibit the dealer from using the voucher to offset any such 
     other rebate or discount;
       (4) require dealers to disclose to the person trading in an 
     eligible trade-in vehicle the best estimate of the scrappage 
     value of such vehicle and to permit the dealer to retain $50 
     of any amounts paid to the dealer for scrappage of the 
     automobile as payment for any administrative costs to the 
     dealer associated with participation in the Program;
       (5) establish a process by which persons who qualify for a 
     rebate under subsection (c)(3) may apply for such rebate;
       (6) consistent with subsection (c)(2), establish 
     requirements and procedures for the disposal of eligible 
     trade-in vehicles and provide such information as may be 
     necessary to entities engaged in such disposal to ensure that 
     such vehicles are disposed of in accordance with such 
     requirements and procedures, including--
       (A) requirements for the removal and appropriate 
     disposition of refrigerants, antifreeze, lead products, 
     mercury switches, and such other toxic or hazardous vehicle 
     components prior to the crushing or shredding of an eligible 
     trade-in vehicle, in accordance with rules established by the 
     Secretary in consultation with the Administrator of the 
     Environmental Protection Agency, and in accordance with other 
     applicable Federal or State requirements;
       (B) a mechanism for dealers to certify to the Secretary 
     that each eligible trade-in vehicle will be transferred to an 
     entity that will ensure that the vehicle is disposed of, in 
     accordance with such requirements and procedures, and to 
     submit the vehicle identification numbers of the vehicles 
     disposed of and the new fuel efficient automobile purchased 
     with each voucher; and
       (C) a list of entities to which dealers may transfer 
     eligible trade-in vehicles for disposal;
       (7) consistent with subsection (c)(2), establish 
     requirements and procedures for the disposal of eligible 
     trade-in vehicles and provide such information as may be 
     necessary to entities engaged in such disposal to ensure that 
     such vehicles are disposed of in accordance with such 
     requirements and procedures; and
       (8) provide for the enforcement of the penalties described 
     in subsection (e).
       (e) Anti-Fraud Provisions.--
       (1) Violation.--It shall be unlawful for any person to 
     knowingly violate any provision under this section or any 
     regulations issued pursuant to subsection (d).
       (2) Penalties.--Any person who commits a violation 
     described in paragraph (1) shall be liable to the United 
     States Government for a civil penalty of not more than 
     $15,000 for each violation.
       (f) Information to Consumers and Dealers.--Not later than 
     30 days after the date of the enactment of this Act, and 
     promptly upon the update of any relevant information, the 
     Secretary shall make available on an Internet website and 
     through other means determined by the Secretary information 
     about the Program, including--

[[Page S5843]]

       (1) how to determine if a vehicle is an eligible trade-in 
     vehicle;
       (2) how to participate in the Program, including how to 
     determine participating dealers; and
       (3) a comprehensive list, by make and model, of new fuel 
     efficient automobiles meeting the requirements of the 
     Program.

     Once such information is available, the Secretary shall 
     conduct a public awareness campaign to inform consumers about 
     the Program and where to obtain additional information.
       (g) Recordkeeping and Report.--
       (1) Database.--The Secretary shall maintain a database of 
     the vehicle identification numbers of all new fuel efficient 
     vehicles purchased or leased and all eligible trade-in 
     vehicles disposed of under the Program.
       (2) Report.--Not later than 60 days after the termination 
     date described in subsection (c)(1)(A)(ii), the Secretary 
     shall submit a report to the Committee on Energy and Commerce 
     of the House of Representatives and the Committee on 
     Commerce, Science, and Transportation of the Senate 
     describing the efficacy of the Program, including--
       (A) a description of Program results, including--
       (i) the total number and amount of vouchers issued for 
     purchase or lease of new fuel efficient automobiles by 
     manufacturer (including aggregate information concerning the 
     make, model, model year) and category of automobile;
       (ii) aggregate information regarding the make, model, model 
     year, and manufacturing location of vehicles traded in under 
     the Program; and
       (iii) the location of sale or lease;
       (B) an estimate of the overall increase in fuel efficiency 
     in terms of miles per gallon, total annual oil savings, and 
     total annual greenhouse gas reductions, as a result of the 
     Program; and
       (C) an estimate of the overall economic and employment 
     effects of the Program.
       (h) Exclusion of Vouchers and Rebates From Income.--
       (1) For purposes of all federal programs.--A voucher issued 
     under the Program or a cash rebate issued under subsection 
     (c)(3) shall not be regarded as income and shall not be 
     regarded as a resource for the month of receipt of the 
     voucher or rebate and the following 12 months, for purposes 
     of determining the eligibility of the recipient of the 
     voucher or rebate (or the recipient's spouse or other family 
     or household members) for benefits or assistance, or the 
     amount or extent of benefits or assistance, under any Federal 
     program.
       (2) For purposes of taxation.--A voucher issued under the 
     Program or a cash rebate issued under subsection (c)(3) shall 
     not be considered as gross income for purposes of the 
     Internal Revenue Code of 1986.
       (i) Definitions.--As used in this section--
       (1) the term ``passenger automobile'' means a passenger 
     automobile, as defined in section 32901(a)(18) of title 49, 
     United States Code, that has a combined fuel economy value of 
     at least 22 miles per gallon;
       (2) the term ``category 1 truck'' means a nonpassenger 
     automobile, as defined in section 32901(a)(17) of title 49, 
     United States Code, that has a combined fuel economy value of 
     at least 18 miles per gallon, except that such term does not 
     include a category 2 truck;
       (3) the term ``category 2 truck'' means a nonpassenger 
     automobile, as defined in section 32901(a)(17) of title 49, 
     United States Code, that is a large van or a large pickup, as 
     categorized by the Secretary using the method used by the 
     Environmental Protection Agency and described in the report 
     entitled ``Light-Duty Automotive Technology and Fuel Economy 
     Trends: 1975 through 2008'';
       (4) the term ``category 3 truck'' means a work truck, as 
     defined in section 32901(a)(19) of title 49, United States 
     Code;
       (5) the term ``combined fuel economy value'' means--
       (A) with respect to a new fuel efficient automobile, the 
     number, expressed in miles per gallon, centered below the 
     words ``Combined Fuel Economy'' on the label required to be 
     affixed or caused to be affixed on a new automobile pursuant 
     to subpart D of part 600 of title 40, Code of Federal 
     Regulations;
       (B) with respect to an eligible trade-in vehicle, the 
     equivalent of the number described in subparagraph (A), and 
     posted under the words ``Estimated New EPA MPG'' and above 
     the word ``Combined'' for vehicles of model year 1984 through 
     2007, or posted under the words ``New EPA MPG'' and above the 
     word ``Combined'' for vehicles of model year 2008 or later on 
     the fueleconomy.gov website of the Environmental Protection 
     Agency for the make, model, and year of such vehicle; or
       (C) with respect to an eligible trade-in vehicle 
     manufactured between model years 1978 through 1984, the 
     equivalent of the number described in subparagraph (A) as 
     determined by the Secretary (and posted on the website of the 
     National Highway Traffic Safety Administration) using data 
     maintained by the Environmental Protection Agency for the 
     make, model, and year of such vehicle;
       (6) the term ``dealer'' means a person licensed by a State 
     who engages in the sale of new automobiles to ultimate 
     purchasers;
       (7) the term ``eligible trade-in vehicle'' means an 
     automobile or a work truck (as such terms are defined in 
     section 32901(a) of title 49, United States Code) that, at 
     the time it is presented for trade-in under this section--
       (A) is in drivable condition;
       (B) has been continuously insured consistent with the 
     applicable State law and registered to the same owner for a 
     period of not less than 1 year immediately prior to such 
     trade-in;
       (C) was manufactured less than 25 years before the date of 
     the trade-in; and
       (D) in the case of an automobile, has a combined fuel 
     economy value of 18 miles per gallon or less;
       (8) the term ``new fuel efficient automobile'' means an 
     automobile described in paragraph (1), (2), (3), or (4)--
       (A) the equitable or legal title of which has not been 
     transferred to any person other than the ultimate purchaser;
       (B) that carries a manufacturer's suggested retail price of 
     $45,000 or less;
       (C) that--
       (i) in the case of passenger automobiles, category 1 
     trucks, or category 2 trucks, is certified to applicable 
     standards under section 86.1811-04 of title 40, Code of 
     Federal Regulations; or
       (ii) in the case of category 3 trucks, is certified to the 
     applicable vehicle or engine standards under section 86.1816-
     08, 86.007-11, or 86.008-10 of title 40, Code of Federal 
     Regulations; and
       (D) that has the combined fuel economy value of--
       (i) 22 miles per gallon for a passenger automobile;
       (ii) 18 miles per gallon for a category 1 truck; or
       (iii) 15 miles per gallon for a category 2 truck;
       (9) the term ``Program'' means the Drive America Forward 
     Program established by this section;
       (10) the term ``qualifying lease'' means a lease of an 
     automobile for a period of not less than 5 years;
       (11) the term ``scrappage value'' means the amount received 
     by the dealer for a vehicle upon transferring title of such 
     vehicle to the person responsible for ensuring the 
     dismantling and destroying the vehicle;
       (12) the term ``Secretary'' means the Secretary of 
     Transportation acting through the National Highway Traffic 
     Safety Administration;
       (13) the term ``ultimate purchaser'' means, with respect to 
     any new automobile, the first person who in good faith 
     purchases such automobile for purposes other than resale; and
       (14) the term ``vehicle identification number'' means the 
     17-character number used by the automobile industry to 
     identify individual automobiles.

     SEC. 3. REALLOCATION OF APPROPRIATIONS.

       From the amounts appropriated under the American Recovery 
     and Reinvestment Act of 2009 (Public Law 111-5), the Director 
     of the Office of Management and Budget may allocate such sums 
     as the Director determines to be necessary to carry out the 
     Drive America Forward Program established under this Act.
                                 ______
                                 
      By Mr. FEINGOLD (for himself, Ms. Snowe, Mrs. Lincoln, Mr. 
        Sanders, and Mr. Dodd):
  S. 1137. A bill to amend the Elementary and Secondary Education Act 
of 1965 to establish a Volunteer Teacher Advisory Committee; to the 
Committee on Health, Education, Labor, and Pensions.
  Mr. FEINGOLD. Mr. President, I am today introducing the Teachers at 
the Table Act of 2009. This bill is the Senate companion to legislation 
introduced in the House of Representatives by Representative Carolyn 
McCarthy of New York and Representative Lee Terry of Nebraska and would 
create a Volunteer Teacher Advisory Committee to advise Congress and 
the Department of Education on the impact of the Elementary and 
Secondary Education Act, ESEA, also known as No Child Left Behind, 
NCLB, on students, their families, and the classroom learning 
environment. The teachers serving on this committee would be chosen 
from past or present State or national Teachers of the Year and would 
be competitively selected by the Secretary of Education and the 
majority and minority leaders of both the Senate and the House of 
Representatives.
  Every year I travel to each of Wisconsin's 72 counties to hold a 
listening session to listen to Wisconsinites' concerns and answer their 
questions. Since NCLB was enacted in early 2002, education has rated as 
one of the top issues brought up at these listening sessions. I have 
received feedback from constituents about the noble intentions of NCLB, 
but I have also heard about the multitude of implementation problems 
with the law's provisions. The feedback from teachers, parents, school 
administrators, and school board members has been invaluable over the 
past 7 years and has guided many of my education policymaking 
decisions.
  As Congress seeks to undertake the reauthorization of ESEA this year, 
it is my hope that this legislation can be part of the reauthorization. 
Feedback

[[Page S5844]]

from good teachers is absolutely vital to understanding how federal 
education policy is impacting classroom instruction around the country. 
This legislation seeks to help ensure that continuous feedback is 
provided to Congress about how the reauthorized ESEA is impacting 
student achievement and closing the persistent achievement gap that 
exists in our Nation.
  The Teachers at the Table bill I am introducing today seeks to help 
ensure that Congress and the Department of Education receive high-
quality yearly feedback on how ESEA/NCLB is impacting classroom 
learning around the country. The teachers who will serve on this 
committee represent some of the best that teaching has to offer. The 
bill would create a committee of 20 teachers, with 4 selected by the 
Secretary of Education and 4 selected by each of the majority and 
minority leaders in the Senate and House of Representatives. These 
teachers would serve 2-year terms on the advisory committee and would 
work to prepare annual reports to Congress as well as quarterly updates 
on the law's implementation.
  Every State and every school district is different and this 
legislation ensures that the teacher advisory committee will represent 
a wide range of viewpoints. The bill specifies that the volunteer 
teacher advisory committee should include teachers from diverse 
geographic areas, teachers who teach different grade levels, and 
teachers from a variety of specialty areas. Creating a diverse 
committee will help ensure that the committee presents a broad range of 
viewpoints on ESEA/NCLB to Congress and the Department of Education.
  Much work needs to be done this year to reform many of the mandates 
of ESEA/NCLB and I look forward to working with my colleagues during 
the reauthorization to make those necessary changes. One thing is 
certain whatever form the reauthorized ESEA takes, there will be a need 
for consistent feedback from a diverse range of viewpoints.
  We need to ensure that the voices of students, educators, parents, 
and administrators, who are on the frontlines of education reform in 
our country, are heard during the reauthorization of ESEA and going 
forward during the reauthorized law's implementation in years to come. 
This bill seeks to help address that need by enlisting the service of 
some of America's best teachers in providing information to Federal 
education policymakers. The advisory committee created by this 
legislation will provide nationwide feedback and will allow Congress to 
hear about ESEA/NCLB directly from those who deal with the law and its 
consequences on a daily basis.
                                 ______
                                 
      By Mrs. FEINSTEIN (for herself and Mrs. Boxer):
  S. 1138. A bill to amend the Reclamation Wastewater and Groundwater 
Study and Facilities Act to expand the Bay Area Regional Recycling 
Program, and for other purposes; to the Committee on Energy and Natural 
Resources.
  Mrs. FEINSTEIN. Mr. President, I rise on behalf of myself and Senator 
Boxer to introduce the Bay Area Regional Water Recycling Program 
Expansion Act of 2009, which will reduce demand for limited fresh water 
supplies by providing recycled water to 6 communities across the Bay 
Area.
  It will make 6 additional Bay Area recycled water projects eligible 
for a 25 percent Federal cost-share, and expand the authorizations for 
two more, totaling $38,075,000. The activities authorized by the new 
legislation include installing new piping, storage tanks, and pump 
stations to convey the recycled water to a number of cities across the 
Bay Area.
  These projects collectively will save 2.6 billion gallons per year of 
regional water supply by providing a new water supply of clean treated 
wastewater for irrigation and industrial use. It will free up the 
amount needed to supply 24,225 households in the growing Bay Area 
region. And to the regional agencies, over 3,500 local green jobs will 
be supported by this legislation.
  The adoption of water recycling technology is an invaluable 
conservation method which will result in 8,000 acre-feet of new and 
reliable water which will reduce demand on fresh water from the Delta.
  California is facing phenomenal water supply challenges that are 
affecting our economy, our communities and our environment.
  California's water infrastructure is woefully out of date. Drought, 
population growth, climate variability, ecosystem needs and a broken 
Delta are making it even more difficult to manage our water system and 
deliver reliable supplies.
  And unless we take action to address climate change, we could lose a 
significant portion of the Sierra snowpack, which stores water for 2/3 
of California, by 2100.
  Increasing the capability for and use of recycled water will help 
address California's cycles of drought and reduce dependence on water 
from the troubled Bay-Delta ecosystem.
  Water recycling projects are already under way in several local Bay 
Area communities, and have qualified for Federal funding under the Bay 
Area Regional Water Recycling Program. This program allows local water 
managers to treat wastewater and use the clean, recycled water for 
landscape irrigation and other uses, including at golf courses, 
schools, city parks and other municipal facilities. Under the new 
legislation, the six additional Bay Area communities would be allowed 
to work with the Federal Bureau of Reclamation to use water supplies 
more efficiently.
  With the increasing strain on Bay-Delta and other natural resources, 
it is vital that we look to adopt innovative water recycling 
technologies which sustain permanent clean water supplies and support 
existing water resources and local economies.
  Nine Bay Area congressional representatives in the House put this 
regional approach together, and I'd like to recognize and thank them 
for their leadership: George Miller, D-Martinez, Pete Stark, D-Fremont, 
Ellen Tauscher, D-Concord, Anna Eshoo, D-Palo Alto, Mike Honda, D-San 
Jose, Lynn Woolsey, D-Petaluma, Jerry McNerney, D-Pleasanton, Zoe 
Lofgren, D-San Jose and Jackie Speier, D-San Mateo, worked together to 
address the Bay Area's water needs.
  This bill reflects a federal-local partnership and will provide 
communities in the San Francisco Bay Area with reliable and sustainable 
water supplies, and be a benchmark for other major American cities.
  Declining water supplies affects people from all across the United 
States. Now is the time to invest in new water technologies, such as 
water recycling, to meet increasing needs. Wastewater recycling is an 
important part of a multifaceted water supply strategy that also 
includes surface and groundwater storage, improved conveyance, 
conservation, and desalination.
  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. 1138

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Bay Area Regional Water 
     Recycling Program Expansion Act of 2009''.

     SEC. 2. PROJECT AUTHORIZATIONS.

       (a) In General.--The Reclamation Wastewater and Groundwater 
     Study and Facilities Act (43 U.S.C. 390h et seq.) (as amended 
     by section 512(a) of the Consolidated Natural Resources Act 
     of 2008) is amended by adding at the end the following:

     ``SEC. 1649. CCCSD-CONCORD RECYCLED WATER PROJECT.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the Central Contra Costa Sanitary District, California, is 
     authorized to participate in the design, planning, and 
     construction of recycled water distribution systems.
       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $1,800,000.

     ``SEC. 1650. CENTRAL DUBLIN RECYCLED WATER DISTRIBUTION AND 
                   RETROFIT PROJECT.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the Dublin San Ramon Services District, California, is 
     authorized to participate in the design, planning, and 
     construction of recycled water system facilities.

[[Page S5845]]

       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $1,150,000.

     ``SEC. 1651. PETALUMA RECYCLED WATER PROJECT, PHASES 2A, 2B, 
                   AND 3.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the City of Petaluma, California, is authorized to 
     participate in the design, planning, and construction of 
     recycled water system facilities.
       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $6,000,000.

     ``SEC. 1652. CENTRAL REDWOOD CITY RECYCLED WATER PROJECT.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the City of Redwood City, California, is authorized to 
     participate in the design, planning, and construction of 
     recycled water system facilities.
       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $8,000,000.

     ``SEC. 1653. PALO ALTO RECYCLED WATER PIPELINE PROJECT.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the City of Palo Alto, California, is authorized to 
     participate in the design, planning, and construction of 
     recycled water system facilities.
       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $8,250,000.

     ``SEC. 1654. IRONHOUSE SANITARY DISTRICT (ISD) ANTIOCH 
                   RECYCLED WATER PROJECT.

       ``(a) Authorization.--The Secretary, in cooperation with 
     the Ironhouse Sanitary District (ISD), California, is 
     authorized to participate in the design, planning, and 
     construction of recycled water distribution systems.
       ``(b) Cost Share.--The Federal share of the cost of the 
     project authorized by this section shall not exceed 25 
     percent of the total cost of the project.
       ``(c) Limitation.--The Secretary shall not provide funds 
     for the operation and maintenance of the project authorized 
     by this section.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $7,000,000.''.
       (b) Project Implementation.--In carrying out sections 1642 
     through 1648 of the Reclamation Wastewater and Groundwater 
     Study and Facilities Act, and sections 1649 through 1654 of 
     such Act, as added by subsection (a), the Secretary shall 
     enter into individual agreements with the San Francisco Bay 
     Area Regional Water Recycling implementing agencies to fund 
     the projects through the Bay Area Clean Water Agencies 
     (BACWA) or its successor, and shall include in such 
     agreements a provision for the reimbursement of construction 
     costs, including those construction costs incurred prior to 
     the enactment of this Act.
       (c) Clerical Amendments.--The table of contents of the 
     Reclamation Projects Authorization and Adjustment Act of 1992 
     (43 U.S.C. prec. 371) (as amended by section 512(a) of the 
     Consolidated Natural Resources Act of 2008) is amended by 
     inserting after the item relating to section 1648 the 
     following new items:

``Sec. 1649. CCCSD-Concord recycled water project.
``Sec. 1650. Central Dublin recycled water distribution and retrofit 
              project.
``Sec. 1651. Petaluma recycled water project, phases 2a, 2b, and 3.
``Sec. 1652. Central Redwood City recycled water project.
``Sec. 1653. Palo Alto recycled water pipeline project.
``Sec. 1654. Ironhouse Sanitary District (ISD) Antioch recycled water 
              project.''.

     SEC. 3. MODIFICATION TO AUTHORIZED PROJECTS.

       (a) Antioch Recycled Water Project.--Section 1644(d) of the 
     Reclamation Wastewater and Groundwater Study and Facilities 
     Act (43 U.S.C. 390h-27) (as amended by section 512(a) of the 
     Consolidated Natural Resources Act of 2008) is amended by 
     striking ``$2,250,000'' and inserting ``$3,125,000''.
       (b) South Bay Advanced Recycled Water Treatment Facility.--
     Section 1648(d) of the Reclamation Wastewater and Groundwater 
     Study and Facilities Act (43 U.S.C. 390h-31) (as amended by 
     section 512(a) of the Consolidated Natural Resources Act of 
     2008) is amended by striking ``$8,250,000'' and inserting 
     ``$13,250,000''.
                                 ______
                                 
      By Mr. WYDEN:
  S. 1139. A bill to require the Secretary of Agriculture to enter into 
a property conveyance with the city of Wallowa, Oregon, and for other 
purposes; to the Committee on Energy and Natural Resources.
  Mr. WYDEN. Mr. President, today I am pleased to introduce two bills 
that will provide two important communities in rural Oregon with the 
means to promote their cultural history and their economic development 
opportunities, S. 1139 and S. 1140.
  Like anywhere in America, the leaders in rural communities in my 
state are working every day to build the best place they can. And in 
many rural communities in my state, that means not much happens without 
the Federal Government involved. Like many places in the Western United 
States, the Federal Government owns much of the land surrounding these 
small communities. To be sure, many of these lands are treasures; they 
are the source of a vibrant tourism economy; an attraction for 
individuals and businesses to move to the region; and the daily outlet 
for the people lucky enough to live there.
  By the same token, this high percentage of Federal land ownership 
sometimes limits the ability of local governments and civic leaders to 
solve problems and serve the public. The Federal Government can and 
should be an active partner in advancing communities and improving a 
region's quality of life.
  So today I am introducing legislation that demonstrates the 
possibilities that can come from a quality Federal Government 
partnership with a proactive, innovative community that faces 
challenging economic conditions and a dominant pattern of Federal land 
ownership.
  My first bill, the La Pine Land Conveyance Act, would convey two 
parcels of property to Deschutes County, Oregon. The bill directs the 
transfer of Bureau of Land Management BLM, lands to Deschutes County, 
that will enable the small town of La Pine to develop rodeo and 
equestrian facilities, public parks, and other recreation facilities.
  La Pine has a set of unique challenges well known to the people of 
Deschutes County. The town recently incorporated, and with 
incorporation has come a feeling in the community that good things can 
happen if they work together to make their town as good as it can 
possibly be.
  My bill proposes the transfer of 320 acres of BLM land contiguous to 
the La Pine city limit, on its western boundary. Ownership of this 
location will enable construction of public equestrian and rodeo 
facilities that have become increasingly important in La Pine. The 
property is within reasonable walking distance of downtown, creating an 
ideal parade route for the annual 4th of July Frontier Days parade. In 
addition, the land will provide a location for development of ball 
fields, parks, and recreation facilities, which can be developed as the 
town grows and budgets allow.
  The La Pine Rodeo and Frontier Days events are currently facing the 
last year they can hold their events on the currently utilized location 
because that private property is being developed for other uses. So 
looking towards the Federal Government, who controls the vast majority 
of land in the La Pine area, to find a solution provides the right kind 
of partnership between the federal and local government.
  My bill also directs the transfer of approximately 750 acres of BLM 
lands to Deschutes County for the purpose of expanding the town's 
wastewater treatment operation.
  More than two years ago my office participated in discussions between 
the La Pine community leaders and the BLM concerning the La Pine 
community's need for land to serve public purposes. Due to staffing 
limitations, BLM asked the City to choose one top priority for a land 
transfer under the Recreation and Public Purposes Act. The La Pine City 
Council responded immediately that its top priority was

[[Page S5846]]

the acquisition of land to enable expansion of their sewer district.
  To date, the land has not been transferred, which make this small 
community unable to be competitive for state and federal economic 
stimulus funds.
  This project is too important to let languish. Perhaps the most 
important issue affecting water quality in Deschutes County involves 
the threat to groundwater and the Deschutes River from household septic 
systems in southern Deschutes County, the region around La Pine. This 
project directly reduces nitrate loading into south county groundwater 
in two ways. First, by enabling expansion of the District service 
boundary to residential areas where septic systems are generating 
elevated groundwater nitrate levels; and second, by closing the current 
location for spreading treated effluent, over a relatively high 
groundwater area, to this new location which is judged not to threaten 
groundwater. That is why I am introducing legislation today to make 
sure this transfer moves forward.
  My second bill, the Wallowa Forest Service Compound Conveyance Act 
would convey an old Forest Service Ranger Station compound to the City 
of Wallowa, Oregon. In Wallowa County, this Forest Service compound was 
built by the Civilian Conservation Corps in the 1930's. For many years 
it was the center of town and this site continues to represent the 
natural and cultural history of one of eastern Oregon's most beautiful 
communities. The City of Wallowa, along with County Commissioners, the 
local arts organizations, and a broad group of community leaders intend 
to restore this important example of Pacific Northwest rustic 
architecture and tribute to bygone times, making a valuable community 
interpretive center at this site. The conveyance of this property will 
allow the community to move forward with this project. The community is 
currently working to list the Ranger Station on the National Register 
of Historic Places, and ownership by the City will allow this coalition 
to restore the buildings and again develop a vibrant community center. 
Oregon Public Broadcasting aired a segment depicting an early 20th 
century railroad logging community--a significant part of the rich and 
diverse history and traditions that will be preserved and celebrated as 
this Forest Service Compound is developed as an interpretive center.
  I want to express my thanks to all the citizens and community leaders 
that have worked to build their communities and develop these projects. 
They represent the pioneering spirit and vision that defines my State.
  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. 1139

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Wallowa Forest Service 
     Compound Conveyance Act''.

     SEC. 2. CONVEYANCE TO CITY OF WALLOWA, OREGON.

       (a) Definitions.--In this Act:
       (1) City.--The term ``City'' means the city of Wallowa, 
     Oregon.
       (2) Secretary.--The term ``Secretary'' means the Secretary 
     of Agriculture.
       (3) Wallowa forest service compound.--The term ``Wallowa 
     Forest Service Compound'' means the Wallowa Ranger Station 
     that is--
       (A) located at 602 West First Street, Wallowa, Oregon; and
       (B) under the jurisdiction of the Secretary.
       (b) Duty of Secretary.--As soon as practicable after the 
     date of enactment of this Act, subject to valid existing 
     rights, the Secretary shall convey to the City, without 
     consideration and by quitclaim deed, all right, title, and 
     interest of the United States, except as provided in 
     subsections (c) and (d), in and to the Wallowa Forest Service 
     Compound.
       (c) Use of Wallowa Forest Service Compound.--As a condition 
     of the conveyance under subsection (b), the City shall--
       (1) use the Wallowa Forest Service Compound as an 
     interpretive center;
       (2) ensure that the Wallowa Forest Service Compound is 
     managed by a nonprofit entity; and
       (3) agree to manage the Wallowa Forest Service Compound--
       (A) with due consideration and protection for the historic 
     values of the Wallowa Forest Service Compound; and
       (B) in accordance with such terms and conditions as are 
     agreed to by the Secretary and the City.
       (d) Reversion.--In the quitclaim deed to the City, the 
     Secretary shall provide that the Wallowa Forest Service 
     Compound shall revert to the Secretary, at the election of 
     the Secretary, if the Wallowa Forest Service Compound is--
       (1) used for a purpose other than the purposes described in 
     subsection (c)(1); or
       (2) managed by the City in a manner that is inconsistent 
     with subsection(c)(3).
                                 ______
                                 
      By Mr. WYDEN:
  S. 1140. A bill to direct the Secretary of the Interior to convey 
certain Federal land to Deschutes County, Oregon; to the Committee on 
Energy and Natural Resources.
  Mr. WYDEN. 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. 1140

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``La Pine Land Conveyance 
     Act''.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) County.--The term ``County'' means the County of 
     Deschutes, Oregon.
       (2) Map.--The term ``map'' means the map entitled ``La Pine 
     Proposed Land Transfer Proposal'' and dated May [__], 2009.
       (3) Secretary.--The term ``Secretary'' means the Secretary 
     of the Interior, acting through the Director of the Bureau of 
     Land Management.

     SEC. 3. CONVEYANCE OF LAND TO THE COUNTY OF DESCHUTES, 
                   OREGON.

       (a) In General.--As soon as practicable after the date of 
     enactment of this Act, subject to valid existing rights, and 
     notwithstanding the land use planning requirements of 
     sections 202 and 203 of the Federal Land Policy and 
     Management Act of 1976 (43 U.S.C. 1712, 1713), the Secretary 
     shall convey to the County, without consideration, all right, 
     title, and interest of the United States in and to the land 
     described in subsection (b).
       (b) Description of Land.--The land referred to in 
     subsection (a) consists of--
       (1) approximately 320 acres of land managed by the Bureau 
     of Land Management, Prineville District, Oregon, depicted on 
     the map as ``parcel A''; and
       (2) approximately 750 acres of land managed by the Bureau 
     of Land Management, Prineville District, Oregon, depicted on 
     the map as ``parcel B''.
       (c) Map on File.--The map shall be on file and available 
     for public inspection in the appropriate offices of the 
     Bureau of Land Management.
       (d) Use of Conveyed Land.--
       (1) In general.--The land conveyed under subsection (a) 
     shall be used as a rodeo ground, public sewer system, or 
     other public purpose consistent with the Act of June 14, 1926 
     (commonly known as the ``Recreation and Public Purposes 
     Act'') (43 U.S.C. 869 et seq.).
       (2) Limitations.--The land conveyed under subsection (a)--
       (A) shall not be used for residential or commercial 
     purposes; and
       (B) shall be used consistent with the Act of June 14, 1926 
     (commonly known as the ``Recreation and Public Purposes 
     Act'') (43 U.S.C. 869 et seq.).
       (3) Additional terms and conditions.--The Secretary may 
     require such additional terms and conditions for the 
     conveyance as the Secretary determines to be appropriate to 
     protect the interests of the United States.
       (e) Administrative Costs.--The Secretary shall require the 
     County to pay all survey costs and other administrative costs 
     necessary for the preparation and completion of any patents 
     for, and transfers of title to, the land under subsection 
     (a).
       (f) Reversion.--
       (1) In general.--If the land conveyed under subsection (a) 
     ceases to be used for the public purpose for which the land 
     was conveyed, the land shall, at the discretion of the 
     Secretary, revert to the United States.
       (2) Responsibility of district.--If the Secretary 
     determines under paragraph (1) that the land should revert to 
     the United States and that the land is contaminated with 
     hazardous waste, the County shall be responsible for 
     remediation of the contamination.
                                 ______
                                 
      By Mrs. FEINSTEIN (for herself and Mr. Bond):
  S. 1141. A bill to extend certain trade preferences to certain least-
developed countries, and for other purposes; to the Committee on 
Finance.
  Mrs. FEINSTEIN. Mr. President, I rise today with Senator Bond to 
introduce the Tariff Relief Assistance for Developing Economies Act of 
2009 to help some of the world's poorest countries sustain vital export 
industries and promote economic growth and political stability.
  I worked with former senator Gordon Smith on this bill in the past 
and I am proud to move it forward in the 111th Congress.

[[Page S5847]]

  This legislation will provide duty free and quota free benefits for 
garments and other products similar to those afforded to beneficiary 
countries under the Africa Growth and Opportunity Act, AGOA.
  The countries covered by this legislation are the 14 Least Developed 
Countries, LDCs, as defined by the United Nations and the U.S. State 
Department, which are not covered by any current U.S. trade preference 
program: Afghanistan, Bangladesh, Bhutan, Cambodia, Kiribati, Laos, 
Maldives, Nepal, Samoa, Solomon Islands, East Timor, Tuvalu, Vanuatu, 
and Yemen.
  The bill also includes Sri Lanka as an eligible country.
  To be eligible for the benefits provided under our bill, a country 
must demonstrate that it is making continual progress toward 
establishing rule of law, political pluralism, the right to due 
process, and a market-based economy that protects private property 
rights. Our legislation would help promote democracy while sustaining 
vital export industries and creating employment opportunities.
  The beneficiary countries of this legislation are among the poorest 
countries in the world.
  Nepal has per capita income of $240. Unemployment in Bangladesh 
stands at 40 percent. Approximately 36 percent of Cambodia's population 
lives below the poverty line.
  Each country faces critical challenges in the years ahead including 
poor health care, insufficient educational opportunities, high HIV/AIDS 
rates, and the effects of war and civil strife.
  The U.S. must take a leadership role in providing much needed 
assistance to the people of these countries.
  Yet humanitarian and development assistance should not be the sum 
total of our efforts to put these countries on the road to economic 
prosperity and political stability.
  Indeed, the key for sustained growth and rising standards of living 
will be the ability of each of these countries to create vital export 
industries to compete in a free and open global marketplace.
  We should help these countries help themselves by opening the U.S. 
market to their exports.
  Success in that endeavor will ultimately allow these countries to 
become less dependent on foreign aid and allow the U.S. to provide 
assistance to countries in greater need.
  The garment industry is a key part of the manufacturing sector in 
some of these countries.
  In Nepal, the garment industry is entirely export oriented and 
accounts for 40 percent of foreign exchange earnings. It employs over 
100,000 workers--half of them women--and sustains the livelihood of 
over 350,000 people.
  The United States is the largest market for Nepalese garments and 
accounts for 80-90 percent of Nepal's total exports every year.
  In Cambodia, approximately 250,000 Cambodians work in the garment 
industry supporting approximately one million dependents. The garment 
industry accounts for more than 90 percent of Cambodia's export 
earnings.
  In Bangladesh, the garment industry accounts for 75 percent of export 
earnings. The industry employs 1.8 million people, 90 percent of whom 
are women, and sustains the livelihoods of 10 to 15 million people.
  Despite the poverty seen in these countries and the importance of the 
garment industry and the U.S. market, they face some of the highest 
U.S. tariffs in the world, averaging over 15 percent. In contrast, 
countries like Japan and our European partners face tariffs that are 
nearly zero.
  Surely we can do better. This legislation will help these countries 
compete in the U.S. market and let their citizens know that Americans 
are committed to helping them realize a better future for themselves 
and their families.
  Doing so is consistent with U.S. goals to combat poverty, 
instability, and terrorism in a critical part of the world. We should 
not forget that of the approximately 265 million people that live in 
the TRADE Act countries, almost 200 million are Muslim.
  The impact on U.S. jobs will be minimal. Currently, the beneficiary 
countries under this legislation account for only 4 percent of U.S. 
textile and apparel imports, compared to 24 percent for China, and 72 
percent for the rest of the world.
  These countries will continue to be small players in the U.S. market, 
but the benefits of this legislation will have a major impact on their 
export economies.
  At a time when we are trying to rebuild the image of the U.S. around 
the world, we need legislation such as this to show the best of America 
and American values. It will provide a vital component to our 
development strategy and add another tool to the war on terror. I urge 
my colleagues to support this bill.
  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. 1141

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Tariff Relief Assistance for 
     Developing Economies Act of 2009'' or the ``TRADE Act of 
     2009''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) It is in the mutual interest of the United States and 
     least-developed countries to promote stable and sustainable 
     economic growth and development.
       (2) Trade and investment are powerful economic tools and 
     can be used to reduce poverty and raise the standard of 
     living in a country.
       (3) A country that is open to trade may increase its 
     economic growth.
       (4) Trade and investment often lead to employment 
     opportunities and often help alleviate poverty.
       (5) Least-developed countries have a particular challenge 
     in meeting the economic requirements and competitiveness of 
     globalization and international markets.
       (6) The United States has recognized the benefits that 
     international trade provides to least-developed countries by 
     enacting the Generalized System of Preferences and trade 
     benefits for developing countries in the Caribbean, Andean, 
     and sub-Saharan African regions of the world.
       (7) Enhanced trade with least-developed Muslim countries, 
     including Yemen, Afghanistan, and Bangladesh, is consistent 
     with other United States objectives of encouraging a strong 
     private sector and individual economic empowerment in those 
     countries.
       (8) Offering least-developed countries enhanced trade 
     preferences will encourage both higher levels of trade and 
     direct investment in support of positive economic and 
     political developments throughout the world.
       (9) Encouraging the reciprocal reduction of trade and 
     investment barriers will enhance the benefits of trade and 
     investment as well as enhance commercial and political ties 
     between the United States and the countries designated for 
     benefits under this Act.
       (10) Economic opportunity and engagement in the global 
     trading system together with support for democratic 
     institutions and a respect for human rights are mutually 
     reinforcing objectives and key elements of a policy to 
     confront and defeat global terrorism.

     SEC. 3. DEFINITIONS.

       In this Act:
       (1) Beneficiary trade act of 2009 country.--The term 
     ``beneficiary TRADE Act of 2009 country'' means a TRADE Act 
     of 2009 country that the President has determined is eligible 
     for preferential treatment under section 5.
       (2) Former trade act of 2009 beneficiary country.--The term 
     ``former TRADE Act of 2009 beneficiary country'' means a 
     country that, after being designated as a beneficiary TRADE 
     Act of 2009 country under this Act, ceased to be designated 
     as such a country by reason of its entering into a free trade 
     agreement with the United States.
       (3) TRADE act of 2009 country.--The term ``TRADE Act of 
     2009 country'' means a country listed in subsection (b) or 
     (c) of section 4.

     SEC. 4. AUTHORITY TO DESIGNATE; ELIGIBILITY REQUIREMENTS.

       (a) Authority To Designate.--
       (1) In general.--Notwithstanding any other provision of 
     law, the President is authorized to designate a TRADE Act of 
     2009 country as a beneficiary TRADE Act of 2009 country 
     eligible for benefits described in section 5--
       (A) if the President determines that the country meets the 
     requirements set forth in section 104 of the African Growth 
     and Opportunity Act (19 U.S.C. 3703); and
       (B) subject to the authority granted to the President under 
     subsections (a), (d), and (e) of section 502 of the Trade Act 
     of 1974 (19 U.S.C. 2462 (a), (d), and (e)), if the country 
     otherwise meets the eligibility criteria set forth in such 
     section 502.
       (2) Application of section 104.--Section 104 of the African 
     Growth and Opportunity Act shall be applied for purposes of 
     paragraph (1) by substituting ``TRADE Act of 2009 country'' 
     for ``sub-Saharan African country'' each place it appears.
       (b) Countries Eligible for Designation.--For purposes of 
     this Act, the term ``TRADE Act of 2009 country'' refers to 
     the following or their successor political entities:

[[Page S5848]]

       (1) Afghanistan.
       (2) Bangladesh.
       (3) Bhutan.
       (4) Cambodia.
       (5) Kiribati.
       (6) Lao People's Democratic Republic.
       (7) Maldives.
       (8) Nepal.
       (9) Samoa.
       (10) Solomon Islands.
       (11) Timor-Leste (East Timor).
       (12) Tuvalu.
       (13) Vanuatu.
       (14) Yemen.
       (c) Sri Lanka Economic Emergency Support.--For purposes of 
     this Act, the President may also designate Sri Lanka as 
     beneficiary TRADE Act of 2009 country eligible for benefits 
     described in section 5.

     SEC. 5. TRADE ENHANCEMENT.

       The preferential treatment described in this section 
     includes the following:
       (1) Preferential tariff treatment for certain articles.--
       (A) In general.--The President may provide duty-free 
     treatment for any article described in section 503(b)(1) (B) 
     through (G) of the Trade Act of 1974 (19 U.S.C. 2463(b)(1) 
     (B) through (G)) that is the growth, product, or manufacture 
     of a beneficiary TRADE Act of 2009 country, if, after 
     receiving the advice of the International Trade Commission in 
     accordance with section 503(e) of the Trade Act of 1974 (19 
     U.S.C. 2463(e)), the President determines that such article 
     is not import-sensitive in the context of imports from 
     beneficiary TRADE Act of 2009 countries.
       (B) Rules of origin.--The duty-free treatment provided 
     under subparagraph (A) shall apply to any article described 
     in that subparagraph that meets the requirements of section 
     503(a)(2) of the Trade Act of 1974 (19 U.S.C. 2463(a)(2)), 
     except that--
       (i) if the cost or value of materials produced in the 
     customs territory of the United States is included with 
     respect to that article, an amount not to exceed 15 percent 
     of the appraised value of the article at the time it is 
     entered that is attributed to such United States cost or 
     value may be applied toward determining the percentage 
     referred to in subparagraph (A) of section 503(a)(2) of the 
     Trade Act of 1974 (19 U.S.C. 2463(a)(2)); and
       (ii) the cost or value of the materials included with 
     respect to that article that are produced in one or more 
     beneficiary TRADE Act of 2009 countries or former beneficiary 
     TRADE Act of 2009 countries shall be applied in determining 
     such percentage.
       (2) Textile and apparel articles.--
       (A) In general.--The preferential treatment relating to 
     textile and apparel articles described in section 112 (a) and 
     (b) (1) and (2) of the African Growth and Opportunity Act (19 
     U.S.C. 3721 (a) and (b) (1) and (2)) shall apply to textile 
     and apparel articles imported directly into the customs 
     territory of the United States from a beneficiary TRADE Act 
     of 2009 country and such section shall be applied for 
     purposes of this subparagraph by substituting ``beneficiary 
     TRADE Act of 2009 country'' and ``beneficiary TRADE Act of 
     2009 countries'' for ``beneficiary sub-Saharan African 
     country'' and ``beneficiary sub-Saharan African countries'', 
     respectively, each place such terms appear.
       (B) Apparel articles assembled from regional and other 
     fabric.--In applying such section 112, apparel articles 
     wholly assembled in one or more beneficiary TRADE Act of 2009 
     countries or former beneficiary TRADE Act of 2009 countries, 
     or both, from fabric wholly formed in one or more beneficiary 
     TRADE Act of 2009 countries or former beneficiary TRADE Act 
     of 2009 countries, or both, from yarn originating either in 
     the United States or one or more beneficiary TRADE Act of 
     2009 countries or former beneficiary TRADE Act of 2009 
     countries, or both (including fabrics not formed from yarns, 
     if such fabrics are classifiable under heading 5602 or 5603 
     of the Harmonized Tariff Schedule of the United States and 
     are wholly formed and cut in the United States, in one or 
     more beneficiary TRADE Act of 2009 countries or former 
     beneficiary TRADE Act of 2009 countries, or any combination 
     thereof), whether or not the apparel articles are also made 
     from any of the fabrics, fabric components formed, or 
     components knit-to-shape described in section 112(b) (1) or 
     (2) of the African Growth and Opportunity Act (19 U.S.C. 
     3721(b) (1) and (2)) (unless the apparel articles are made 
     exclusively from any of the fabrics, fabric components 
     formed, or components knit-to-shape described in such section 
     112(b) (1) or (2)) subject to the following:
       (i) Limitations on benefits.--

       (I) In general.--Preferential treatment under this 
     subparagraph shall be extended in the 1-year period beginning 
     January 1, 2009, and in each of the succeeding 10 1-year 
     periods, to imports of apparel articles described in this 
     subparagraph in an amount not to exceed the applicable 
     percentage of the aggregate square meter equivalents of all 
     apparel articles imported into the United States in the most 
     recent 12-month period for which data are available.
       (II) Applicable percentage.--For purposes of this clause, 
     the term ``applicable percentage'' means 11 percent for the 
     1-year period beginning January 1, 2009, increased in each of 
     the 10 succeeding 1-year period by equal increments, so that 
     for the period beginning January 1, 2019, the applicable 
     percentage does not exceed 14 percent.

       (ii) Special rule.--

       (I) In general.--Subject to clause (i), preferential 
     treatment described in this subparagraph shall be extended 
     through December 31, 2016, for apparel articles wholly 
     assembled in one or more beneficiary TRADE Act of 2009 
     countries or former beneficiary TRADE Act of 2009 countries, 
     or both, regardless of the country of origin of the yarn or 
     fabric used to make such articles.
       (II) Country limitations.--

       (aa) Small suppliers.--If, during the preceding 1-year 
     period beginning on January 1 for which data are available, 
     imports from a beneficiary TRADE Act of 2009 country are less 
     than 1 percent of the aggregate square meter equivalents of 
     all apparel articles imported into the United States during 
     such period, such imports may increase to an amount that is 
     equal to not more than 1.5 percent of the aggregate square 
     meter equivalents of all apparel articles imported into the 
     United States during such period.
       (bb) Other suppliers.--If during the preceding 1-year 
     period beginning on January 1 for which data are available, 
     imports from a beneficiary TRADE Act of 2009 country are at 
     least 1 percent of the aggregate square meter equivalents of 
     all apparel articles imported into the United States during 
     such period, such imports may increase, during each 
     subsequent 12-month period, by an amount that is equal to not 
     more than one-third of 1 percent of the aggregate square 
     meter equivalents of all apparel articles imported into the 
     United States.
       (cc) Aggregate country limit.--In no case may the aggregate 
     quantity of textile and apparel articles imported into the 
     United States under this subparagraph exceed the applicable 
     percentage set forth in clause (i).
       (C) Technical amendment.--Section 6002(a)(2)(B) of the 
     Africa Investment Incentive Act of 2006 (Public Law 109-432) 
     is amended by inserting before ``by striking'' the following: 
     ``in paragraph (3),''.
       (D) Other restrictions.--The provisions of section 112 (b) 
     (3)(B), (4), (5), (6), (7), and (8), and (e), and section 113 
     of the African Growth and Opportunity Act (19 U.S.C. 3721 (b) 
     (3)(B), (4), (5), (6), (7), and (8), and (e), and 3722) shall 
     apply with respect to the preferential treatment extended 
     under this Act to a beneficiary TRADE Act of 2009 country by 
     substituting ``beneficiary TRADE Act of 2009 country'' for 
     ``beneficiary sub-Saharan African country'' and ``beneficiary 
     TRADE Act of 2009 countries'' and ``former beneficiary TRADE 
     Act of 2009 countries'' for ``beneficiary sub-Saharan African 
     countries'' and ``former sub-Saharan African countries'', 
     respectively, wherever appropriate.

     SEC. 6. REPORTING REQUIREMENT.

       The President shall monitor, review, and report to 
     Congress, not later than 1 year after the date of the 
     enactment of this Act, and annually thereafter, on the 
     implementation of this Act and on the trade and investment 
     policy of the United States with respect to the TRADE Act of 
     2009 countries.

     SEC. 7. TERMINATION OF PREFERENTIAL TREATMENT.

       No duty-free treatment or other preferential treatment 
     extended to a beneficiary TRADE Act of 2009 country under 
     this Act shall remain in effect after December 31, 2019.

     SEC. 8. EFFECTIVE DATE.

       The provisions of this Act shall take effect on January 1, 
     2009.
                                 ______
                                 
      By Mr. REED (for himself and Ms. Mikulski):
  S. 1142. A bill to amend the Federal Food, Drug, and Cosmetic Act 
with respect to inclusion of effectiveness information in drug and 
device labeling and advertising; to the Committee on Health, Education, 
Labor, and Pensions.
  Mr. REED. Mr. President, today I introduce the Informed Health Care 
Decision Making Act of 2009. I am introducing this legislation along 
with my colleague Senator Mikulski because every American deserves to 
have the full information regarding drugs and devices prescribed by 
their provider.
  Even though the amount of money spent to reach the public about drugs 
and devices is greater than five billion dollars annually, the most 
fundamental information--information about how well the drug or device 
actually works--is generally absent. In 2007, the Institute of Medicine 
conducted a workshop regarding the public's understanding of drugs and 
confirmed the importance for patients and physicians of having 
standardized and quantitative information about the product before 
making health care decisions.
  Researchers at Dartmouth University have documented that replacing 
the current narrative information contained in drug advertisements with 
simplified, factual information, will enable patients to play an active 
role in health care decision making. In fact, similar to the nutrition 
facts boxes that are required on our Nation's packaged food supply, 
this research demonstrated that a drug facts box will actually help 
physicians make better health care choices.
  If the research is not enough proof that this type of streamlined 
information will be beneficial, the Food and

[[Page S5849]]

Drug Administration's, FDA, Risk Communications Advisory Committee, a 
committee specifically designed to counsel the agency on how to 
strengthen the communication of risks and benefits of FDA-regulated 
products to the public, unanimously recommended that the FDA adopt 
standardized, quantitative summaries of risks and benefits in a drug 
facts box format.
  As such, the Informed Health Care Decision Making Act of 2009 would 
require the FDA to determine if the information provided in a drug 
facts box, or a similar format, would improve health care decision 
making by clinicians and patients, and report to Congress on that 
determination. If the report determines that a specific standardized, 
quantitative format would be beneficial, the FDA must issue regulations 
to implement the format.
  Regardless of the FDA's determination, it is important for clinicians 
and patients to be able to compare the similarities, differences, 
benefits, and risks of drugs and devices. As such, the legislation 
would require the Agency for Healthcare Research and Quality to 
establish a multi-stakeholder process for developing and periodically 
updating methodological standards and criteria for comparative clinical 
effectiveness research. This would include standards and criteria for 
the sources of evidence and the adequacy of evidence that are 
appropriate for the inclusion of comparative clinical effectiveness 
information in labeling and print advertisements.
  Upon completion of these standards, the legislation requires drug 
labels and print advertisements to include information on the clinical 
effectiveness of a product--compared to other products approved for the 
same health condition for the same patient demographic subpopulation--
or a disclosure that there is no such information, if another product 
has not been approved for the same use. The potential of such a 
disclosure should be a powerful incentive for manufacturers to fund 
comparative effectiveness research.
  It is my hope that as we embark upon meaningful health care reform, 
my colleagues will join me in supporting this bill and other 
initiatives to improve the health care decision making of both patients 
and clinicians.
  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. 1142

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Informed Health Care 
     Decision Making Act''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) National randomized controlled trials have found that 
     replacing the brief summary of drug advertisements with a 
     drug facts box improved consumer knowledge and judgments. In 
     such trials, consumers who were presented with a drug facts 
     box more accurately perceived the side effects and benefits 
     of a drug, and were more than twice as likely to choose the 
     superior drug.
       (2)(A) In 2007, the Institute of Medicine conducted a 
     workshop that highlighted that the public has a limited 
     understanding of the benefits and risks of drugs. The 
     workshop also highlighted that it is important to--
       (i) provide patients and physicians with the best possible 
     information for making informed decisions about the use of 
     pharmaceuticals;
       (ii) employ quantitative and standardized approaches when 
     trying to evaluate pharmaceutical benefit-risk; and
       (iii) develop and validate improved tools for communicating 
     pharmaceutical benefit-risk information to patients and 
     physicians.
       (B) The general agreement of the workshop was that the Food 
     and Drug Administration should pilot test a drug facts box.
       (3) On February 27, 2009, the Food and Drug 
     Administration's Risk Communication Advisory Committee made 
     the following unanimous recommendations:
       (A) The Food and Drug Administration should adopt a single 
     standard document for communicating essential information 
     about pharmaceuticals.
       (B) That standard document should include quantitative 
     summaries of risks and benefits, along with use and 
     precaution information.
       (C) The Food and Drug Administration should adopt the drug 
     facts box format as its standard.

     SEC. 3. PRESENTATION OF DRUG BENEFIT AND RISK INFORMATION.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this Act as the ``Secretary''), acting 
     through the Commissioner of Food and Drugs, shall determine 
     whether standardized, quantitative summaries of the benefits 
     and risks of drugs in a tabular or drug facts box format, or 
     any alternative format, in the labeling and print advertising 
     of such drugs would improve health care decision making by 
     clinicians and patients and consumers.
       (b) Review and Consultation.--In making the determination 
     under subsection (a), the Secretary shall review all 
     available scientific evidence and consult with drug 
     manufacturers, clinicians, patients and consumers, experts in 
     health literacy, and representatives of racial and ethnic 
     minorities.
       (c) Report.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary shall submit to the 
     Congress a report that provides--
       (1) the determination by the Secretary under subsection 
     (a); and
       (2) the reasoning and analysis underlying that 
     determination.
       (d) Authority.--
       (1) In general.--If the Secretary determines under 
     subsection (a) that standardized, quantitative summaries of 
     the benefits and risks of drugs in a tabular or drug facts 
     box format, or any alternative format, in the labeling and 
     print advertising of such drugs would improve health care 
     decision making by clinicians and patients and consumers, 
     then the Secretary, not later than 1 year after the date of 
     submission of the report under subsection (c), shall 
     promulgate regulations as necessary to implement such format.
       (2) Objective and up-to-date information.--In carrying out 
     paragraph (1), the Secretary shall ensure that the 
     information presented in a summary described under such 
     paragraph is objective and up-to-date, and is the result of a 
     review process that considers the totality of published and 
     unpublished data.
       (3) Posting of information.--In carrying out paragraph (1), 
     the Secretary shall post the information presented in a 
     summary described under such paragraph on the Internet Web 
     site of the Food and Drug Administration.

     SEC. 4. STANDARDS FOR COMPARATIVE CLINICAL EFFECTIVENESS 
                   INFORMATION.

       (a) In General.--The Secretary, acting through the 
     Commissioner of Food and Drugs, shall establish and 
     periodically update methodological standards and criteria for 
     the sources of evidence and the adequacy and degree of 
     evidence that are appropriate for inclusion of comparative 
     clinical effectiveness information in labeling and 
     advertisements under subsections (f), (n)(3), and (r) of 
     section 502 of the Federal Food, Drug, and Cosmetic Act (as 
     amended by section 5).
       (b) Requirements.--The standards and criteria established 
     under subsection (a) shall ensure that comparative clinical 
     effectiveness information provides reliable and useful 
     information that improves health care decision making, 
     adheres to rigorous scientific standards, and is produced 
     through a transparent process that includes consultation with 
     stakeholders.
       (c) Consultation.--In carrying out subsection (a), the 
     Secretary shall consult with manufacturers of drugs and 
     devices, clinicians, patients and consumers, experts in 
     health literacy, and representatives of racial and ethnic 
     minorities.
       (d) Definition.--For purposes of this section, the term 
     ``comparative clinical effectiveness'' means the clinical 
     outcomes, effectiveness, safety, and clinical appropriateness 
     of a drug or device in comparison to 1 or more drugs or 
     devices, respectively, approved to prevent, diagnose, or 
     treat the same health condition for the same patient 
     demographic subpopulation.

     SEC. 5. DISCLOSURE OF COMPARATIVE CLINICAL EFFECTIVENESS 
                   INFORMATION.

       (a) Comparative Clinical Effectiveness.--Section 201 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321) is 
     amended by adding at the end the following:
       ``(rr) The term `comparative clinical effectiveness' means 
     the clinical outcomes, effectiveness, safety, and clinical 
     appropriateness of a drug or device in comparison to 1 or 
     more drugs or devices, respectively, approved to prevent, 
     diagnose, or treat the same health condition for the same 
     patient demographic subpopulation, on the basis of research 
     that meets standards adopted by the Secretary under section 4 
     of the Informed Health Care Decision Making Act.''.
       (b) Labeling and Advertising Information.--Section 502 of 
     the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 352) is 
     amended--
       (1) in subsection (f), by striking ``for use; and (2)'' and 
     inserting ``for use; (2) such information in brief summary 
     relating to comparative clinical effectiveness as shall be 
     required in regulations which shall be issued by the 
     Secretary in accordance with the procedure specified in 
     section 701(a); and (3)'';
       (2) in subsection (n)(3), by striking ``and effectiveness'' 
     and inserting ``effectiveness, and comparative clinical 
     effectiveness (or a disclosure that there is no such 
     information relating to comparative clinical effectiveness if 
     another drug has been approved for the same use),''; and
       (3) in subsection (r)--
       (A) by striking ``In the case of any'' and inserting ``(1) 
     In the case of any'';
       (B) by striking ``(1) a true'' and inserting ``(A) a 
     true'';
       (C) by striking ``(2) a brief'' and inserting ``(B) a 
     brief''; and

[[Page S5850]]

       (D) by striking ``and contraindications'' and inserting 
     ``contraindications, and, if appropriate after taking into 
     consideration the type of device, effectiveness and 
     comparative clinical effectiveness (or a disclosure that 
     there is no such information relating to comparative clinical 
     effectiveness if another device has been approved for the 
     same use)''.
                                 ______
                                 
      By Mr. DURBIN:
  S. 1143. A bill to amend the Public Health Service Act to establish 
various programs for the recruitment and retention of public health 
workers and to eliminate critical public health workforce shortages in 
Federal, State, local, and tribal public health agencies and health 
centers; to the Committee on Health, Education, Labor, and Pensions.
  Mr. DURBIN. Mr. President, the people who work in public health are 
responsible for some of the most important jobs that protect the lives 
and health of ordinary Americans. The scope of public health includes 
preventing the spread of communicable diseases and pandemics, managing 
the health system's response to biological and chemical attacks, 
fighting food-borne illnesses, assisting communities in preparing for 
disasters, and promoting best health practices.
  The recent outbreak of Influenza A H1N1 virus reminds us how much we 
depend on the people who work in public health. This virus has infected 
thousands of people and caused nearly a hundred deaths worldwide. The 
American people have looked to the Centers for Disease Control and 
Prevention and their State and local health departments to collect 
data, monitor the threat, provide accurate information, and prepare to 
respond if the situation worsens. But even when a pandemic or other 
widespread threat is not imminent, the public health workforce remains 
on the front lines in promoting healthy lifestyles and preventing 
chronic disease.
  Our ability to prevent, respond to, and recover from a pandemic or 
other health challenges depends largely on a strong pipeline of public 
health professionals. Unfortunately, a critical--and growing--shortage 
of public health workers is putting our nation at risk.
  The Association of Schools of Public Health recently reported that 
there were 50,000 fewer public health workers in 2000 than there were 
in 1980. In my home State of Illinois, the average Illinois Department 
of Public Health worker is 48 years old, and 39 percent of the staff 
will be eligible to retire within 5 years. Compounding this problem is 
the fact that 13 percent of agency positions are vacant, and when a new 
hire is found, the average age is 41. The ``graying'' workforce and 
weak pipeline of new public health graduates are problems across all 
levels of government. Nearly half of the federal employees in 
occupations critical to U.S. biodefense will be eligible to retire by 
2012.
  We cannot stay on the same trajectory in the future. We are not 
educating enough people in public health to replace retiring public 
health workers, and the salaries for those who do work in public health 
disciplines are not competitive with comparable employment in the 
private sector. The Association of State and Territorial Health 
Officials reports that in 2004, most of the approximately 6,400 
graduates from accredited schools of public health took jobs in the 
private sector.
  I am pleased to introduce the Public Health Workforce Development Act 
of 2009 today to help address this challenge. This legislation provides 
several common-sense solutions to develop a strong pipeline of public 
health professionals. This bill would provide scholarships to students 
going into public health and provide loan repayment for current public 
health workers in exchange for a commitment to additional years of 
service in public health.
  The legislation also encourages states to set up their own public 
health training programs and creates a scholarship program for mid-
career professionals to maintain or upgrade their training. Finally, it 
creates an online clearinghouse of public health jobs available in the 
Federal Government. Together, these programs will help attract young 
people to a career in public health and give current public health 
professionals incentives to remain in the field in the long-term
  Our health care system today focuses too much on treating sickness, 
at the expense of preserving wellness. As the process of health reform 
moves forward, two key concerns are improving health care quality, 
while holding health care costs down. To do this, we need to focus on 
wellness, preventive care, and effective management of chronic 
conditions, all of which are hallmarks of the public health system. 
This bill will help maintain a strong and effective public health 
system by alleviating the dangerous shortage of public health workers
  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. 1143

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Public Health Workforce 
     Development Act of 2009''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) The ability of the public health system to prevent, 
     respond to, and recover from bioterrorism, acute outbreaks of 
     infectious diseases, or other health threats and emergencies, 
     and to prevent and reduce chronic disease, depends upon the 
     existence of adequate numbers of well-trained public health 
     professionals in Federal, State, local, and tribal public 
     health departments and health centers.
       (2) The public health system has an aging staff nearing 
     retirement with no clear pipeline of highly-skilled and 
     capable employees to fill the void, with the average age of 
     the State public health workforce at 47 years.
       (3) Retirement rates in some State public health agencies 
     were as high as 20 percent as of June 2007, and projected to 
     be as high as 45 percent in 2009.
       (4) The ratio of public health workers to the population 
     has dropped from 219 per 100,000 in 1980 to 158 per 100,000 
     in 2000, while responsibilities of such workers have 
     continued to expand.
       (5) Public health nurses comprise the largest segment of 
     the public health workforce. A study by the Institute of 
     Medicine in 2003 identified nursing as facing one of the most 
     severe shortages of public health workers. The average age of 
     public health nurses is nearly 50 years, with the leaders of 
     State public health nursing averaging more than 30 years of 
     service. In one State nearly 40 percent of the public health 
     nursing workforce was eligible for retirement as of June 
     2007.
       (6) According to the Association of State and Territorial 
     Health Officials, most of the approximately 6,400 graduates 
     from accredited schools of public health took jobs in the 
     private sector in 2004. The Bureau of Labor Statistics 
     projects that there will be an increase in private sector 
     demand for highly-educated graduates in scientific fields 
     during the 10-year period ending in 2017. Public health 
     agencies will have difficulty competing for those highly-
     skilled scientists.
       (7) As of June 2007, approximately 42 percent of the 
     epidemiology workforce in State and territorial health 
     departments lacked formal academic training in epidemiology. 
     States have reported that approximately 47 percent more 
     epidemiologists are needed to adequately prevent and control 
     avian influenza and other emerging diseases.
       (8) The Partnership for Public Service reports that in the 
     field of microbiology, there are more than 4 times as many 
     full-time permanent employees over age 40 as under age 40 at 
     the Centers for Disease Control and Prevention. Among full-
     time permanent employees with medical backgrounds at the 
     Centers for Disease Control and Prevention and the Food and 
     Drug Administration, there are 3 times as many employees over 
     40 years of age as under 40.
       (9) More than 50 percent of States cite the lack of 
     qualified individuals or individuals willing to relocate as 
     being a major barrier to preparedness. A study conducted by 
     the Health Resources and Services Association reported 
     difficulty with recruiting more educated, skilled public 
     health providers to work in traditionally medically 
     underserved areas, such as rural populations. Public health 
     agencies continue to face an unmet need for public health 
     workers who are bilingual and culturally competent.
       (10) Lack of access to advanced education, including 
     baccalaureate nursing and graduate studies, is a significant 
     barrier to upgrading the existing public health workforce, 
     particularly in rural areas.

     SEC. 3. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION 
                   PROGRAMS.

       Part E of title VII of the Public Health Service Act (42 
     U.S.C. 294n et seq.) is amended by adding at the end the 
     following:

``Subpart 3--Public Health Workforce Recruitment and Retention Programs

     ``SEC. 780. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.

       ``(a) Establishment.--The Secretary shall establish the 
     Public Health Workforce Scholarship Program (referred to in 
     this section as the `Program') to assure an adequate supply 
     of public health professionals to eliminate critical public 
     health workforce shortages in Federal, State, local, and 
     tribal public health agencies and health centers.
       ``(b) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1) be accepted for enrollment, or be enrolled, as a 
     full-time student--

[[Page S5851]]

       ``(A) in an accredited (as determined by the Secretary) 
     educational institution in a State or territory; and
       ``(B) in a course of study or program, offered by such 
     institution and approved by the Secretary, leading to a 
     health professions degree (graduate, undergraduate, or 
     associate) or certificate, which may include public health, 
     laboratory sciences, epidemiology, environmental health, 
     health communications, health education and behavioral 
     sciences, information sciences, or public administration;
       ``(2) be a United States citizen;
       ``(3) submit an application to the Secretary to participate 
     in the Program; and
       ``(4) sign and submit to the Secretary, at the time of the 
     submission of such application, a written contract (described 
     in subsection (d)) to serve, upon the completion of the 
     course of study or program involved, for the applicable 
     period of obligated service in the full-time employment of a 
     Federal, State, local, or tribal public health agency or a 
     health center.
       ``(c) Dissemination of Information.--
       ``(1) Application and contract forms.--The Secretary shall 
     disseminate application forms and contract forms to 
     individuals desiring to participate in the Program. The 
     Secretary shall include with such forms--
       ``(A) a fair summary of the rights and liabilities of an 
     individual whose application is approved (and whose contract 
     is accepted) by the Secretary, including in the summary a 
     clear explanation of the damages to which the United States 
     is entitled in the case of the individual's breach of the 
     contract; and
       ``(B) information relating to the service obligation and 
     such other information as may be necessary for the individual 
     to understand the individual's prospective participation in 
     the Program.
       ``(2) Information for schools.--The Secretary shall 
     distribute to health professions schools and other 
     appropriate accredited academic institutions and relevant 
     Federal, State, local, and tribal public health agencies, 
     materials providing information on the Program and shall 
     encourage such schools, institutions, and agencies to 
     disseminate such materials to potentially eligible students.
       ``(3) Understandability and timing.--The application form, 
     contract form, and all other information furnished by the 
     Secretary under this section shall--
       ``(A) be written in a manner calculated to be understood by 
     the average individual applying to participate in the 
     Program; and
       ``(B) be made available by the Secretary on a date 
     sufficiently early to ensure that such individuals have 
     adequate time to carefully review and evaluate such forms and 
     information.
       ``(d) Contract.--The written contract between the Secretary 
     and an individual shall contain--
       ``(1) an agreement on the part of the Secretary that the 
     Secretary will provide the individual with a scholarship for 
     a period of years (not to exceed 4 academic years) during 
     which the individual shall pursue an approved course of study 
     or program to prepare the individual to serve in the public 
     health workforce;
       ``(2) an agreement on the part of the individual that the 
     individual will--
       ``(A) maintain full-time enrollment in the approved course 
     of study or program described in subsection (b)(1) until the 
     individual completes that course of study or program;
       ``(B) while enrolled in the course of study or program, 
     maintain an acceptable level of academic standing (as 
     determined under regulations of the Secretary by the 
     educational institution offering such course of study or 
     program); and
       ``(C) immediately upon graduation, serve in the full-time 
     employment of a Federal, State, local, or tribal public 
     health agency or a health center in a position related to the 
     course of study or program for which the contract was awarded 
     for a period of time (referred to in this section as the 
     `period of obligated service') equal to the greater of--
       ``(i) 1 year for each academic year for which the 
     individual was provided a scholarship under the Program; or
       ``(ii) 2 years;
       ``(3) an agreement by both parties as to the nature and 
     extent of the scholarship assistance, which may include--
       ``(A) payment of the tuition expenses of the individual;
       ``(B) payment of all other reasonable educational expenses 
     of the individual including fees, books, equipment, and 
     laboratory expenses; and
       ``(C) payment of a stipend of not more than $1,200 per 
     month for each month of the academic year involved (indexed 
     to account for increases in the Consumer Price Index);
       ``(4) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this subsection and any obligation of the individual which is 
     conditioned thereon, is contingent upon funds being 
     appropriated for scholarships under this section;
       ``(5) a statement of the damages to which the United States 
     is entitled for the individual's breach of the contract; and
       ``(6) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     the provisions of this section.
       ``(e) Postponing Obligated Service.--With respect to an 
     individual receiving a degree or certificate from a school of 
     medicine, public health, nursing, osteopathic medicine, 
     dentistry, veterinary medicine, optometry, podiatry, 
     pharmacy, psychology, or social work under a scholarship 
     under the Program, the date of the initiation of the period 
     of obligated service may be postponed, upon the submission by 
     the individual of a petition for such postponement and 
     approval by the Secretary, to the date on which the 
     individual completes an approved internship, residency, or 
     other relevant public health advanced training program.
       ``(f) Administrative Provisions.--
       ``(1) Contracts with institutions.--The Secretary may 
     contract with an educational institution in which a 
     participant in the Program is enrolled, for the payment to 
     the educational institution of the amounts of tuition and 
     other reasonable educational expenses described in subsection 
     (d)(3).
       ``(2) Employment ceilings.--Notwithstanding any other 
     provision of law, individuals who have entered into written 
     contracts with the Secretary under this section, while 
     undergoing academic training, shall not be counted against 
     any employment ceiling affecting the Department or any other 
     Federal agency.
       ``(g) Breach of Contract.--An individual who fails to 
     comply with the contract entered into under subsection (d) 
     shall be subject to the same financial penalties as provided 
     for under section 338E for breaches of scholarship contracts 
     under sections 338A.
       ``(h) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section 
     $35,000,000 for each of the fiscal years 2010 through 2015.
       ``(i) Definition.--For purposes of this subpart, the term 
     `health center' has the meaning given such term in section 
     330(a).

     ``SEC. 781. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.

       ``(a) Establishment.--The Secretary shall establish the 
     Public Health Workforce Loan Repayment Program (referred to 
     in this section as the `Program') to assure an adequate 
     supply of public health professionals to eliminate critical 
     public health workforce shortages in Federal, State, local, 
     and tribal public health agencies and in health centers.
       ``(b) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1)(A) be accepted for enrollment, or be enrolled, as a 
     full-time or part-time student in an accredited academic 
     educational institution in a State or territory in the final 
     year of a course of study or program offered by that 
     institution leading to a health professions degree or 
     certificate, which may include a degree (graduate, 
     undergraduate, or associate) or certificate relating to 
     public health, laboratory sciences, epidemiology, 
     environmental health, health communications, health education 
     and behavioral sciences, information sciences, or public 
     administration; or
       ``(B) have graduated, within 10 years, from an accredited 
     educational institution in a State or territory and received 
     a health professions degree (graduate, undergraduate, or 
     associate) or certificate, which may include a degree 
     (graduate, undergraduate, or associate) or certificate 
     relating to public health, laboratory sciences, epidemiology, 
     environmental health, health communications, health education 
     and behavioral sciences, information sciences, or public 
     administration;
       ``(2)(A) in the case of an individual described in 
     paragraph (1)(A), have accepted employment with a Federal, 
     State, local, or tribal public health agency or a health 
     center, as recognized by the Secretary, to commence upon 
     graduation; or
       ``(B) in the case of an individual described in paragraph 
     (1)(B), be employed by, or have accepted employment with, a 
     Federal, State, local, or tribal public health agency or a 
     health center, as recognized by the Secretary;
       ``(3) be a United States citizen;
       ``(4) submit an application to the Secretary to participate 
     in the Program; and
       ``(5) sign and submit to the Secretary, at the time of the 
     submission of such application, a written contract (described 
     in subsection (d)) to serve for the applicable period of 
     obligated service in the full-time employment of a Federal, 
     State, local, or tribal public health agency or a health 
     center.
       ``(c) Dissemination of Information.--
       ``(1) Application and contract forms.--The Secretary shall 
     disseminate application forms and contract forms to 
     individuals desiring to participate in the Program. The 
     Secretary shall include with such forms--
       ``(A) a fair summary of the rights and liabilities of an 
     individual whose application is approved (and whose contract 
     is accepted) by the Secretary, including in the summary a 
     clear explanation of the damages to which the United States 
     is entitled to recover in the case of the individual's breach 
     of the contract; and
       ``(B) information relating to the service obligation and 
     such other information as may be necessary for the individual 
     to understand the individual's prospective participation in 
     the Program.
       ``(2) Information for schools.--The Secretary shall 
     distribute to health professions schools and other 
     appropriate accredited academic institutions and relevant 
     Federal, State, local, and tribal public health agencies and 
     health centers, materials providing information on the 
     Program and shall encourage such schools, institutions, and 
     agencies to disseminate such materials to potentially 
     eligible students.
       ``(3) Understandability and timing.--The application form, 
     contract form, and all

[[Page S5852]]

     other information furnished by the Secretary under this 
     section shall--
       ``(A) be written in a manner calculated to be understood by 
     the average individual applying to participate in the 
     Program; and
       ``(B) be made available by the Secretary on a date 
     sufficiently early to ensure that such individuals have 
     adequate time to carefully review and evaluate such forms and 
     information.
       ``(d) Contract.--The written contract (referred to in this 
     section) between the Secretary and an individual shall 
     contain--
       ``(1) an agreement on the part of the Secretary that the 
     Secretary will repay on behalf of the individual loans 
     incurred by the individual in the pursuit of the relevant 
     public health workforce educational degree or certificate in 
     accordance with the terms of the contract;
       ``(2) an agreement on the part of the individual that the 
     individual will serve, immediately upon graduation in the 
     case of an individual described in subsection (b)(1)(A) 
     service, or in the case of an individual described in 
     subsection (b)(1)(B) continue to serve, in the full-time 
     employment of a Federal, State, local, or tribal public 
     health agency or health center in a position related to the 
     course of study or program for which the contract was awarded 
     for a period of time (referred to in this section as the 
     `period of obligated service') equal to the greater of--
       ``(A) 3 years; or
       ``(B) such longer period of time as determined appropriate 
     by the Secretary and the individual;
       ``(3) an agreement, as appropriate, on the part of the 
     individual to relocate for the entire period of obligated 
     service to a political jurisdiction designated by the 
     Secretary to be a priority service area in exchange for an 
     additional loan repayment incentive amount that does not 
     exceed 20 percent of the individual's eligible loan repayment 
     award per academic year such that the total of the loan 
     repayment and the incentive amount shall not exceed \1/3\ of 
     the eligible loan balance per year;
       ``(4) in the case of an individual described in subsection 
     (b)(1)(A) who is in the final year of study and who has 
     accepted employment with a Federal, State, local, or tribal 
     public health agency or a health center upon graduation, an 
     agreement on the part of the individual to complete the 
     education or training, maintain an acceptable level of 
     academic standing (as determined by the education institution 
     offering the course of study or training), and agree to the 
     period of obligated service;
       ``(5) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this section and any obligation of the individual that is 
     conditioned thereon, is contingent on funds being 
     appropriated for loan repayments under this section;
       ``(6) a statement of the damages to which the United States 
     is entitled, under this section for the individual's breach 
     of the contract; and
       ``(7) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     this section.
       ``(e) Payments.--
       ``(1) In general.--A loan repayment provided for an 
     individual under a written contract under the Program shall 
     consist of payment, in accordance with paragraph (2), on 
     behalf of the individual of the principal, interest, and 
     related expenses on government and commercial loans received 
     by the individual regarding the undergraduate or graduate 
     education of the individual (or both), which loans were made 
     for--
       ``(A) tuition expenses; or
       ``(B) all other reasonable educational expenses, including 
     fees, books, and laboratory expenses, incurred by the 
     individual.
       ``(2) Payments for years served.--
       ``(A) In general.--For each year of obligated service that 
     an individual contracts to serve under subsection (d) the 
     Secretary may pay up to $35,000 on behalf of the individual 
     for loans described in paragraph (1). With respect to 
     participants under the Program whose total eligible loans are 
     less than $105,000, the Secretary shall pay an amount that 
     does not exceed \1/3\ of the eligible loan balance for each 
     year of obligated service of the individual.
       ``(B) Repayment schedule.--Any arrangement made by the 
     Secretary for the making of loan repayments in accordance 
     with this subsection shall provide that any repayments for a 
     year of obligated service shall be made no later than the end 
     of the fiscal year in which the individual completes such 
     year of service.
       ``(3) Tax liability.--For the purpose of providing 
     reimbursements for tax liability resulting from payments 
     under paragraph (2) on behalf of an individual--
       ``(A) the Secretary shall, in addition to such payments, 
     make payments to the individual in an amount not to exceed 39 
     percent of the total amount of loan repayments made for the 
     taxable year involved; and
       ``(B) may make such additional payments as the Secretary 
     determines to be appropriate with respect to such purpose.
       ``(4) Payment schedule.--The Secretary may enter into an 
     agreement with the holder of any loan for which payments are 
     made under the Program to establish a schedule for the making 
     of such payments.
       ``(f) Postponing Obligated Service.--With respect to an 
     individual receiving a degree or certificate from a school of 
     medicine, public health, nursing, osteopathic medicine, 
     dentistry, veterinary medicine, optometry, podiatry, 
     pharmacy, psychology, or social work, the date of the 
     initiation of the period of obligated service may be 
     postponed, upon the submission by the individual of a 
     petition for such postponement and approval by the Secretary, 
     to the date on which the individual completes an approved 
     internship, residency, or other relevant public health 
     advanced training program.
       ``(g) Administrative Provisions.--
       ``(1) Hiring priority.--Notwithstanding any other provision 
     of law, Federal, State, local, and tribal public health 
     agencies and health centers may give hiring priority to any 
     individual who has qualified for and is willing to execute a 
     contract to participate in the Program.
       ``(2) Employment ceilings.--Notwithstanding any other 
     provision of law, individuals who have entered into written 
     contracts with the Secretary under this section, who are 
     serving as full-time employees of a State, local, or tribal 
     public health agency or a health center, or who are in the 
     last year of public health workforce academic preparation, 
     shall not be counted against any employment ceiling affecting 
     the Department or any other Federal agency.
       ``(h) Breach of Contract.--An individual who fails to 
     comply with the contract entered into under subsection (d) 
     shall be subject to the same financial penalties as provided 
     for under section 338E for breaches of loan repayment 
     contracts under section 338B.
       ``(i) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section 
     $195,000,000 for each of the fiscal years 2010 through 2015.

     ``SEC. 782. GRANTS FOR STATE AND LOCAL PROGRAMS.

       ``(a) In General.--For the purpose of operating State, 
     local, tribal, and health center public health workforce loan 
     repayment programs under this subpart, the Secretary shall 
     award a grant to any public health agency that receives 
     public health preparedness cooperative agreements, or other 
     successor cooperative agreements, from the Department of 
     Health and Human Services.
       ``(b) Requirements.--A State or local loan repayment 
     program operated with a grant under subsection (a) shall 
     incorporate all provisions of the Public Health Workforce 
     Loan Repayment Program under section 781, including the 
     ability to designate priority service areas within the 
     relevant political jurisdiction.
       ``(c) Administration.--The head of the State or local 
     office that receives a grant under subsection (a) shall be 
     responsible for contracting and operating the loan repayment 
     program under the grant.
       ``(d) Rule of Construction.--Nothing in this section shall 
     be construed to obligate or limit any State, local, or tribal 
     government entity from implementing independent or 
     supplemental public health workforce development programs 
     within their borders.

     ``SEC. 783. TRAINING FOR MID-CAREER PUBLIC HEALTH 
                   PROFESSIONALS.

       ``(a) In General.--The Secretary may make grants to, or 
     enter into contracts with, any eligible entity to award 
     scholarships to eligible individuals to enroll in degree or 
     professional training programs for the purpose of enabling 
     mid-career professionals in the public health workforce to 
     receive additional training in the field of public health.
       ``(b) Eligibility.--
       ``(1) Eligible entity.--The term `eligible entity' 
     indicates an accredited educational institution that offers a 
     course of study, certificate program, or professional 
     training program in infectious disease science, medicine, 
     public health, veterinary medicine, or other discipline 
     impacting or influenced by bioterrorism or emerging 
     infectious diseases.
       ``(2) Eligible individuals.--The term `eligible 
     individuals' includes those individuals employed in public 
     health positions at the Federal, State, tribal, or local 
     level or a health center who are interested in retaining or 
     upgrading their education.
       ``(c) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $30,000,000 for each of the fiscal years 2010 through 2015.

     ``SEC. 784. CATALOGUE OF FEDERAL PUBLIC HEALTH WORKFORCE 
                   EMPLOYMENT OPPORTUNITIES.

       ``(a) In General.--The Director of the Office of Personnel 
     Management, in cooperation with the Secretary, shall ensure 
     that, included in the Internet website of the Office of 
     Personnel Management, there is an online catalogue, or link 
     to an online catalogue, of public health workforce employment 
     opportunities in the Federal Government.
       ``(b) Requirements.--To the extent practicable, the 
     catalogue described in subsection (a) shall include--
       ``(1) existing and projected job openings in the Federal 
     public health workforce; and
       ``(2) a general discussion of the occupations that comprise 
     the Federal public health workforce.
       ``(c) Information.--The Secretary shall include a copy of 
     the catalogue described in subsection (a), or a prominent 
     reference to the catalogue, in--
       ``(1) the application forms provided under section 
     780(c)(1); and
       ``(2) the information for schools provided under section 
     780(c)(2).''.
                                 ______
                                 
      By Mr. KOHL (for himself and Mr. Leahy):
  S. 1147. A bill to prevent tobacco smuggling, to ensure the 
collection of

[[Page S5853]]

all tobacco taxes, and for other purposes; to the Committee on the 
Judiciary.
  Mr. KOHL. Mr. President, I rise today with Senator Leahy to introduce 
the Prevent All Cigarette Trafficking, PACT, Act of 2009. As the 
problem of cigarette trafficking continues to worsen, we must provide 
law enforcement officials with the tools they need to crack down on 
cigarette trafficking. The PACT Act closes loopholes in current tobacco 
trafficking laws, enhances penalties for violations, and provides law 
enforcement with new tools to combat the innovative new methods being 
used by cigarette traffickers to distribute their products. Each day we 
delay passage of this important legislation, terrorists and criminals 
raise more money, States lose significant amounts of tax revenue, and 
kids have easy access to tobacco products over the internet.
  The cost to Americans is not merely financial. Tobacco smuggling also 
poses a significant threat to innocent people around the world. It has 
developed into a popular, and highly profitable, means of generating 
revenue for criminal and terrorist organizations. Hezbollah, for 
example, earned $1.5 million between 1996 and 2000 by engaging in 
tobacco trafficking in the U.S. Al Qaeda and Hamas have also generated 
significant revenue from the sale of counterfeit cigarettes. That money 
is often raised right here in the U.S. and it is then funneled back to 
these international terrorist groups. Cutting off financial support to 
terrorist groups is an integral part of the protecting this country 
against future attacks. We can no longer continue to let terrorist 
organizations exploit weaknesses in our tobacco laws to generate 
significant amounts of money. The cost of doing nothing is too great.
  This is not a minor problem. Cigarette smuggling is a multibillion 
dollar a year phenomenon, and it is getting worse. In 1998, the Bureau 
of Alcohol, Tobacco, Firearms and Explosives (BATFE) had six active 
tobacco smuggling investigations. In 2005, that number swelled to 452. 
Today there are more than 400 open cases.
  The number of cases alone, however, does not sufficiently put this 
problem into perspective. The amount of money involved is truly 
astonishing. Cigarette trafficking, including the illegal sale of 
tobacco products over the internet, costs States billions of dollars in 
lost tax revenue each year. It is estimated that we lose $5 billion in 
state revenues due to illegal tobacco sales. As lost tobacco tax 
revenue lines the pockets of criminals and terrorist groups, states are 
being forced to college tuition and restrict access to other public 
programs. Tobacco smuggling may provide some with cheap access to 
cigarettes, but those cheap cigarettes are coming at a significant cost 
to the rest of us.
  According to the Government Accountability Office, each year, 
cigarette trafficking investigations are growing more and more complex, 
and take longer to resolve. More people are selling cigarettes 
illegally, and they are getting better at it. As these cases get 
tougher to solve, we owe it to law enforcement officials to do our part 
to lend a helping hand. The PACT Act enhances BATFE's authority to 
enter premises to investigate and enforce cigarette trafficking laws, 
and increasing penalties for violations. Unless these existing laws are 
strengthened, traffickers will continue to operate with near impunity.
  Just as important, though, we must provide law enforcement with new 
enforcement tools--tools that enable them to combat the cigarette 
smugglers of the 21st century. The internet represents one of those new 
obstacles to enforcement. Illegal tobacco vendors around the world 
evade detection by conducting transactions over the internet, and then 
employing the services of common carriers and the U.S. Postal Service 
to deliver their illegal products around the country. Just a few years 
ago, there were less than 100 vendors selling cigarettes online. Today, 
we estimate that approximately 500 vendors sell illegal tobacco 
products over the internet.
  Without new and innovative enforcement methods, law enforcement will 
not be able to effectively address the growing challenges facing them 
today. The PACT Act sets out to do just that by cutting off the 
delivery. A significant part of this problem involves the shipment of 
contraband cigarettes through the U.S. Postal Service, USPS. This bill 
would cut off access to the USPS by making tobacco products non-
mailable. We would treat cigarettes just like we treat alcohol, making 
it illegal to ship them through the U.S. mails and cutting off a large 
portion of the delivery system.
  It also employs a novel approach, one being used in some of our 
States today, to combat illegal sales of tobacco over the internet. 
Specifically, it will allow the Attorney General, in collaboration with 
State and local law enforcement, to create a list of companies that are 
illegally selling tobacco products. That list will then be distributed 
to legitimate businesses whose services are indispensable to illegal 
internet vendors--common carriers. Once a common carrier knows which 
customers are breaking the law, this bill will ensure that they take 
appropriate action to prevent their companies from being exploited by 
terrorists and other criminals.
  It is important to point out that this bill has been carefully 
negotiated with the common carriers, including UPS, to ensure that it 
does not place any unreasonable burdens on these businesses. In 
recognition of UPS and other common carriers' agreements to not deliver 
cigarettes to individual consumers on a nationwide basis, pursuant to 
agreements with the State of New York, we have exempted them from the 
bill provided this agreement remains in effect.
  In addition to these important law enforcement needs, it is important 
to mention another aspect of this legislation that is equally 
important. One of the primary ways children get access to cigarettes 
today is on the internet and through the mails. The PACT Act now 
contains a strong age verification section that will ensure that online 
vendors are not selling cigarettes to our children. This provision 
would prohibit the sale of tobacco products to children, and it would 
also require sellers to use a method of shipment that requires a 
signature and photo ID check upon delivery. Most States already have 
similar laws on the books, and this would simply make sure that we have 
a national standard to ensure that the internet is not being used to 
evade similar ID checks we require at our grocery and convenience 
stores.
  The recognition that this is a significant problem, along with the 
commonsense approach taken in the PACT Act to combat it, has brought 
together a coalition of strange bedfellows. The legislation has not 
just garnered the support of the law enforcement community, including 
the National Association of Attorneys General, and public health 
advocates, such as the Campaign for Tobacco Free Kids. It also has the 
strong support of tobacco companies like Altria. These groups, who 
sometimes find themselves on opposite sides of these issues, all agree 
that this is an issue begging to be addressed. They all recognize the 
urgent need to provide our law enforcement officials with the tools 
they need to combat a very serious threat to our security and protect 
public health.
  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. 1147

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

     SECTION 1. SHORT TITLE; FINDINGS; PURPOSES.

       (a) Short Title.--This Act may be cited as the ``Prevent 
     All Cigarette Trafficking Act of 2009'' or ``PACT Act''.
       (b) Findings.--Congress finds that--
       (1) the sale of illegal cigarettes and smokeless tobacco 
     products significantly reduces Federal, State, and local 
     government revenues, with Internet sales alone accounting for 
     billions of dollars of lost Federal, State, and local tobacco 
     tax revenue each year;
       (2) Hezbollah, Hamas, al Qaeda, and other terrorist 
     organizations have profited from trafficking in illegal 
     cigarettes or counterfeit cigarette tax stamps;
       (3) terrorist involvement in illicit cigarette trafficking 
     will continue to grow because of the large profits such 
     organizations can earn;
       (4) the sale of illegal cigarettes and smokeless tobacco 
     over the Internet, and through mail, fax, or phone orders, 
     makes it cheaper and easier for children to obtain tobacco 
     products;
       (5) the majority of Internet and other remote sales of 
     cigarettes and smokeless tobacco are being made without 
     adequate precautions to protect against sales to children,

[[Page S5854]]

     without the payment of applicable taxes, and without 
     complying with the nominal registration and reporting 
     requirements in existing Federal law;
       (6) unfair competition from illegal sales of cigarettes and 
     smokeless tobacco is taking billions of dollars of sales away 
     from law-abiding retailers throughout the United States;
       (7) with rising State and local tobacco tax rates, the 
     incentives for the illegal sale of cigarettes and smokeless 
     tobacco have increased;
       (8) the number of active tobacco investigations being 
     conducted by the Bureau of Alcohol, Tobacco, Firearms, and 
     Explosives rose to 452 in 2005;
       (9) the number of Internet vendors in the United States and 
     in foreign countries that sell cigarettes and smokeless 
     tobacco to buyers in the United States increased from only 
     about 40 in 2000 to more than 500 in 2005; and
       (10) the intrastate sale of illegal cigarettes and 
     smokeless tobacco over the Internet has a substantial effect 
     on interstate commerce.
       (c) Purposes.--It is the purpose of this Act to--
       (1) require Internet and other remote sellers of cigarettes 
     and smokeless tobacco to comply with the same laws that apply 
     to law-abiding tobacco retailers;
       (2) create strong disincentives to illegal smuggling of 
     tobacco products;
       (3) provide government enforcement officials with more 
     effective enforcement tools to combat tobacco smuggling;
       (4) make it more difficult for cigarette and smokeless 
     tobacco traffickers to engage in and profit from their 
     illegal activities;
       (5) increase collections of Federal, State, and local 
     excise taxes on cigarettes and smokeless tobacco; and
       (6) prevent and reduce youth access to inexpensive 
     cigarettes and smokeless tobacco through illegal Internet or 
     contraband sales.

     SEC. 2. COLLECTION OF STATE CIGARETTE AND SMOKELESS TOBACCO 
                   TAXES.

       (a) Definitions.--The Act of October 19, 1949 (15 U.S.C. 
     375 et seq.; commonly referred to as the ``Jenkins Act'') 
     (referred to in this Act as the ``Jenkins Act''), is amended 
     by striking the first section and inserting the following:

     ``SECTION 1. DEFINITIONS.

       ``As used in this Act, the following definitions apply:
       ``(1) Attorney general.--The term `attorney general', with 
     respect to a State, means the attorney general or other chief 
     law enforcement officer of the State.
       ``(2) Cigarette.--
       ``(A) In general.--The term `cigarette'--
       ``(i) has the meaning given that term in section 2341 of 
     title 18, United States Code; and
       ``(ii) includes roll-your-own tobacco (as defined in 
     section 5702 of the Internal Revenue Code of 1986).
       ``(B) Exception.--The term `cigarette' does not include a 
     cigar (as defined in section 5702 of the Internal Revenue 
     Code of 1986).
       ``(3) Common carrier.--The term `common carrier' means any 
     person (other than a local messenger service or the United 
     States Postal Service) that holds itself out to the general 
     public as a provider for hire of the transportation by water, 
     land, or air of merchandise (regardless of whether the person 
     actually operates the vessel, vehicle, or aircraft by which 
     the transportation is provided) between a port or place and a 
     port or place in the United States.
       ``(4) Consumer.--The term `consumer'--
       ``(A) means any person that purchases cigarettes or 
     smokeless tobacco; and
       ``(B) does not include any person lawfully operating as a 
     manufacturer, distributor, wholesaler, or retailer of 
     cigarettes or smokeless tobacco.
       ``(5) Delivery sale.--The term `delivery sale' means any 
     sale of cigarettes or smokeless tobacco to a consumer if--
       ``(A) the consumer submits the order for the sale by means 
     of a telephone or other method of voice transmission, the 
     mails, or the Internet or other online service, or the seller 
     is otherwise not in the physical presence of the buyer when 
     the request for purchase or order is made; or
       ``(B) the cigarettes or smokeless tobacco are delivered to 
     the buyer by common carrier, private delivery service, or 
     other method of remote delivery, or the seller is not in the 
     physical presence of the buyer when the buyer obtains 
     possession of the cigarettes or smokeless tobacco.
       ``(6) Delivery seller.--The term `delivery seller' means a 
     person who makes a delivery sale.
       ``(7) Indian country.--The term `Indian country'--
       ``(A) has the meaning given that term in section 1151 of 
     title 18, United States Code, except that within the State of 
     Alaska that term applies only to the Metlakatla Indian 
     Community, Annette Island Reserve; and
       ``(B) includes any other land held by the United States in 
     trust or restricted status for one or more Indian tribes.
       ``(8) Indian tribe.--The term `Indian tribe', `tribe', or 
     `tribal' refers to an Indian tribe as defined in section 4(e) 
     of the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450b(e)) or as listed pursuant to section 104 of 
     the Federally Recognized Indian Tribe List Act of 1994 (25 
     U.S.C. 479a-1).
       ``(9) Interstate commerce.--The term `interstate commerce' 
     means commerce between a State and any place outside the 
     State, commerce between a State and any Indian country in the 
     State, or commerce between points in the same State but 
     through any place outside the State or through any Indian 
     country.
       ``(10) Person.--The term `person' means an individual, 
     corporation, company, association, firm, partnership, 
     society, State government, local government, Indian tribal 
     government, governmental organization of such a government, 
     or joint stock company.
       ``(11) State.--The term `State' means each of the several 
     States of the United States, the District of Columbia, the 
     Commonwealth of Puerto Rico, or any territory or possession 
     of the United States.
       ``(12) Smokeless tobacco.--The term `smokeless tobacco' 
     means any finely cut, ground, powdered, or leaf tobacco, or 
     other product containing tobacco, that is intended to be 
     placed in the oral or nasal cavity or otherwise consumed 
     without being combusted.
       ``(13) Tobacco tax administrator.--The term `tobacco tax 
     administrator' means the State, local, or tribal official 
     duly authorized to collect the tobacco tax or administer the 
     tax law of a State, locality, or tribe, respectively.
       ``(14) Use.--The term `use' includes the consumption, 
     storage, handling, or disposal of cigarettes or smokeless 
     tobacco.''.
       (b) Reports to State Tobacco Tax Administrators.--Section 2 
     of the Jenkins Act (15 U.S.C. 376) is amended--
       (1) by striking ``cigarettes'' each place it appears and 
     inserting ``cigarettes or smokeless tobacco'';
       (2) in subsection (a)--
       (A) in the matter preceding paragraph (1)--
       (i) by inserting ``Contents.--'' after ``(a)'';
       (ii) by striking ``or transfers'' and inserting ``, 
     transfers, or ships'';
       (iii) by inserting ``, locality, or Indian country of an 
     Indian tribe'' after ``a State'';
       (iv) by striking ``to other than a distributor licensed by 
     or located in such State,''; and
       (v) by striking ``or transfer and shipment'' and inserting 
     ``, transfer, or shipment'';
       (B) in paragraph (1)--
       (i) by striking ``with the tobacco tax administrator of the 
     State'' and inserting ``with the Attorney General of the 
     United States and with the tobacco tax administrators of the 
     State and place''; and
       (ii) by striking ``; and'' and inserting the following: ``, 
     as well as telephone numbers for each place of business, a 
     principal electronic mail address, any website addresses, and 
     the name, address, and telephone number of an agent in the 
     State authorized to accept service on behalf of the 
     person;'';
       (C) in paragraph (2), by striking ``and the quantity 
     thereof.'' and inserting ``the quantity thereof, and the 
     name, address, and phone number of the person delivering the 
     shipment to the recipient on behalf of the delivery seller, 
     with all invoice or memoranda information relating to 
     specific customers to be organized by city or town and by zip 
     code; and''; and
       (D) by adding at the end the following:
       ``(3) with respect to each memorandum or invoice filed with 
     a State under paragraph (2), also file copies of the 
     memorandum or invoice with the tobacco tax administrators and 
     chief law enforcement officers of the local governments and 
     Indian tribes operating within the borders of the State that 
     apply their own local or tribal taxes on cigarettes or 
     smokeless tobacco.'';
       (3) in subsection (b)--
       (A) by inserting ``Presumptive Evidence.--'' after ``(b)'';
       (B) by striking ``(1) that'' and inserting ``that''; and
       (C) by striking ``, and (2)'' and all that follows and 
     inserting a period; and
       (4) by adding at the end the following:
       ``(c) Use of Information.--A tobacco tax administrator or 
     chief law enforcement officer who receives a memorandum or 
     invoice under paragraph (2) or (3) of subsection (a) shall 
     use the memorandum or invoice solely for the purposes of the 
     enforcement of this Act and the collection of any taxes owed 
     on related sales of cigarettes and smokeless tobacco, and 
     shall keep confidential any personal information in the 
     memorandum or invoice except as required for such 
     purposes.''.
       (c) Requirements for Delivery Sales.--The Jenkins Act is 
     amended by inserting after section 2 the following:

     ``SEC. 2A. DELIVERY SALES.

       ``(a) In General.--With respect to delivery sales into a 
     specific State and place, each delivery seller shall comply 
     with--
       ``(1) the shipping requirements set forth in subsection 
     (b);
       ``(2) the recordkeeping requirements set forth in 
     subsection (c);
       ``(3) all State, local, tribal, and other laws generally 
     applicable to sales of cigarettes or smokeless tobacco as if 
     the delivery sales occurred entirely within the specific 
     State and place, including laws imposing--
       ``(A) excise taxes;
       ``(B) licensing and tax-stamping requirements;
       ``(C) restrictions on sales to minors; and
       ``(D) other payment obligations or legal requirements 
     relating to the sale, distribution, or delivery of cigarettes 
     or smokeless tobacco; and
       ``(4) the tax collection requirements set forth in 
     subsection (d).
       ``(b) Shipping and Packaging.--
       ``(1) Required statement.--For any shipping package 
     containing cigarettes or smokeless tobacco, the delivery 
     seller shall include on the bill of lading, if any, and on

[[Page S5855]]

     the outside of the shipping package, on the same surface as 
     the delivery address, a clear and conspicuous statement 
     providing as follows: `CIGARETTES/SMOKELESS TOBACCO: FEDERAL 
     LAW REQUIRES THE PAYMENT OF ALL APPLICABLE EXCISE TAXES, AND 
     COMPLIANCE WITH APPLICABLE LICENSING AND TAX-STAMPING 
     OBLIGATIONS'.
       ``(2) Failure to label.--Any shipping package described in 
     paragraph (1) that is not labeled in accordance with that 
     paragraph shall be treated as nondeliverable matter by a 
     common carrier or other delivery service, if the common 
     carrier or other delivery service knows or should know the 
     package contains cigarettes or smokeless tobacco. If a common 
     carrier or other delivery service believes a package is being 
     submitted for delivery in violation of paragraph (1), it may 
     require the person submitting the package for delivery to 
     establish that it is not being sent in violation of paragraph 
     (1) before accepting the package for delivery. Nothing in 
     this paragraph shall require the common carrier or other 
     delivery service to open any package to determine its 
     contents.
       ``(3) Weight restriction.--A delivery seller shall not 
     sell, offer for sale, deliver, or cause to be delivered in 
     any single sale or single delivery any cigarettes or 
     smokeless tobacco weighing more than 10 pounds.
       ``(4) Age verification.--
       ``(A) In general.--A delivery seller who mails or ships 
     tobacco products--
       ``(i) shall not sell, deliver, or cause to be delivered any 
     tobacco products to a person under the minimum age required 
     for the legal sale or purchase of tobacco products, as 
     determined by the applicable law at the place of delivery;
       ``(ii) shall use a method of mailing or shipping that 
     requires--

       ``(I) the purchaser placing the delivery sale order, or an 
     adult who is at least the minimum age required for the legal 
     sale or purchase of tobacco products, as determined by the 
     applicable law at the place of delivery, to sign to accept 
     delivery of the shipping container at the delivery address; 
     and
       ``(II) the person who signs to accept delivery of the 
     shipping container to provide proof, in the form of a valid, 
     government-issued identification bearing a photograph of the 
     individual, that the person is at least the minimum age 
     required for the legal sale or purchase of tobacco products, 
     as determined by the applicable law at the place of delivery; 
     and

       ``(iii) shall not accept a delivery sale order from a 
     person without--

       ``(I) obtaining the full name, birth date, and residential 
     address of that person; and
       ``(II) verifying the information provided in subclause (I), 
     through the use of a commercially available database or 
     aggregate of databases, consisting primarily of data from 
     government sources, that are regularly used by government and 
     businesses for the purpose of age and identity verification 
     and authentication, to ensure that the purchaser is at least 
     the minimum age required for the legal sale or purchase of 
     tobacco products, as determined by the applicable law at the 
     place of delivery.

       ``(B) Limitation.--No database being used for age and 
     identity verification under subparagraph (A)(iii) shall be in 
     the possession or under the control of the delivery seller, 
     or be subject to any changes or supplementation by the 
     delivery seller.
       ``(c) Records.--
       ``(1) In general.--Each delivery seller shall keep a record 
     of any delivery sale, including all of the information 
     described in section 2(a)(2), organized by the State, and 
     within the State, by the city or town and by zip code, into 
     which the delivery sale is so made.
       ``(2) Record retention.--Records of a delivery sale shall 
     be kept as described in paragraph (1) until the end of the 
     4th full calendar year that begins after the date of the 
     delivery sale.
       ``(3) Access for officials.--Records kept under paragraph 
     (1) shall be made available to tobacco tax administrators of 
     the States, to local governments and Indian tribes that apply 
     local or tribal taxes on cigarettes or smokeless tobacco, to 
     the attorneys general of the States, to the chief law 
     enforcement officers of the local governments and Indian 
     tribes, and to the Attorney General of the United States in 
     order to ensure the compliance of persons making delivery 
     sales with the requirements of this Act.
       ``(d) Delivery.--
       ``(1) In general.--Except as provided in paragraph (2), no 
     delivery seller may sell or deliver to any consumer, or 
     tender to any common carrier or other delivery service, any 
     cigarettes or smokeless tobacco pursuant to a delivery sale 
     unless, in advance of the sale, delivery, or tender--
       ``(A) any cigarette or smokeless tobacco excise tax that is 
     imposed by the State in which the cigarettes or smokeless 
     tobacco are to be delivered has been paid to the State;
       ``(B) any cigarette or smokeless tobacco excise tax that is 
     imposed by the local government of the place in which the 
     cigarettes or smokeless tobacco are to be delivered has been 
     paid to the local government; and
       ``(C) any required stamps or other indicia that the excise 
     tax has been paid are properly affixed or applied to the 
     cigarettes or smokeless tobacco.
       ``(2) Exception.--Paragraph (1) does not apply to a 
     delivery sale of smokeless tobacco if the law of the State or 
     local government of the place where the smokeless tobacco is 
     to be delivered requires or otherwise provides that delivery 
     sellers collect the excise tax from the consumer and remit 
     the excise tax to the State or local government, and the 
     delivery seller complies with the requirement.
       ``(e) List of Unregistered or Noncompliant Delivery 
     Sellers.--
       ``(1) In general.--
       ``(A) Initial list.--Not later than 90 days after this 
     subsection goes into effect under the Prevent All Cigarette 
     Trafficking Act of 2009, the Attorney General of the United 
     States shall compile a list of delivery sellers of cigarettes 
     or smokeless tobacco that have not registered with the 
     Attorney General of the United States pursuant to section 
     2(a), or that are otherwise not in compliance with this Act, 
     and--
       ``(i) distribute the list to--

       ``(I) the attorney general and tax administrator of every 
     State;
       ``(II) common carriers and other persons that deliver small 
     packages to consumers in interstate commerce, including the 
     United States Postal Service; and
       ``(III) any other person that the Attorney General of the 
     United States determines can promote the effective 
     enforcement of this Act; and

       ``(ii) publicize and make the list available to any other 
     person engaged in the business of interstate deliveries or 
     who delivers cigarettes or smokeless tobacco in or into any 
     State.
       ``(B) List contents.--To the extent known, the Attorney 
     General of the United States shall include, for each delivery 
     seller on the list described in subparagraph (A)--
       ``(i) all names the delivery seller uses or has used in the 
     transaction of its business or on packages delivered to 
     customers;
       ``(ii) all addresses from which the delivery seller does or 
     has done business, or ships or has shipped cigarettes or 
     smokeless tobacco;
       ``(iii) the website addresses, primary e-mail address, and 
     phone number of the delivery seller; and
       ``(iv) any other information that the Attorney General of 
     the United States determines would facilitate compliance with 
     this subsection by recipients of the list.
       ``(C) Updating.--The Attorney General of the United States 
     shall update and distribute the list described in 
     subparagraph (A) at least once every 4 months, and may 
     distribute the list and any updates by regular mail, 
     electronic mail, or any other reasonable means, or by 
     providing recipients with access to the list through a 
     nonpublic website that the Attorney General of the United 
     States regularly updates.
       ``(D) State, local, or tribal additions.--The Attorney 
     General of the United States shall include in the list 
     described in subparagraph (A) any noncomplying delivery 
     sellers identified by any State, local, or tribal government 
     under paragraph (6), and shall distribute the list to the 
     attorney general or chief law enforcement official and the 
     tax administrator of any government submitting any such 
     information, and to any common carriers or other persons who 
     deliver small packages to consumers identified by any 
     government pursuant to paragraph (6).
       ``(E) Accuracy and completeness of list of noncomplying 
     delivery sellers.--In preparing and revising the list 
     described in subparagraph (A), the Attorney General of the 
     United States shall--
       ``(i) use reasonable procedures to ensure maximum possible 
     accuracy and completeness of the records and information 
     relied on for the purpose of determining that a delivery 
     seller is not in compliance with this Act;
       ``(ii) not later than 14 days before including a delivery 
     seller on the list, make a reasonable attempt to send notice 
     to the delivery seller by letter, electronic mail, or other 
     means that the delivery seller is being placed on the list, 
     which shall cite the relevant provisions of this Act and the 
     specific reasons for which the delivery seller is being 
     placed on the list;
       ``(iii) provide an opportunity to the delivery seller to 
     challenge placement on the list;
       ``(iv) investigate each challenge described in clause (iii) 
     by contacting the relevant Federal, State, tribal, and local 
     law enforcement officials, and provide the specific findings 
     and results of the investigation to the delivery seller not 
     later than 30 days after the date on which the challenge is 
     made; and
       ``(v) if the Attorney General of the United States 
     determines that the basis for including a delivery seller on 
     the list is inaccurate, based on incomplete information, or 
     cannot be verified, promptly remove the delivery seller from 
     the list as appropriate and notify each appropriate Federal, 
     State, tribal, and local authority of the determination.
       ``(F) Confidentiality.--The list described in subparagraph 
     (A) shall be confidential, and any person receiving the list 
     shall maintain the confidentiality of the list and may 
     deliver the list, for enforcement purposes, to any government 
     official or to any common carrier or other person that 
     delivers tobacco products or small packages to consumers. 
     Nothing in this section shall prohibit a common carrier, the 
     United States Postal Service, or any other person receiving 
     the list from discussing with a listed delivery seller the 
     inclusion of the delivery seller on the list and the 
     resulting effects on any services requested by the listed 
     delivery seller.
       ``(2) Prohibition on delivery.--
       ``(A) In general.--Commencing on the date that is 60 days 
     after the date of the initial distribution or availability of 
     the list

[[Page S5856]]

     described in paragraph (1)(A), no person who receives the 
     list under paragraph (1), and no person who delivers 
     cigarettes or smokeless tobacco to consumers, shall knowingly 
     complete, cause to be completed, or complete its portion of a 
     delivery of any package for any person whose name and address 
     are on the list, unless--
       ``(i) the person making the delivery knows or believes in 
     good faith that the item does not include cigarettes or 
     smokeless tobacco;
       ``(ii) the delivery is made to a person lawfully engaged in 
     the business of manufacturing, distributing, or selling 
     cigarettes or smokeless tobacco; or
       ``(iii) the package being delivered weighs more than 100 
     pounds and the person making the delivery does not know or 
     have reasonable cause to believe that the package contains 
     cigarettes or smokeless tobacco.
       ``(B) Implementation of updates.--Commencing on the date 
     that is 30 days after the date of the distribution or 
     availability of any updates or corrections to the list 
     described in paragraph (1)(A), all recipients and all common 
     carriers or other persons that deliver cigarettes or 
     smokeless tobacco to consumers shall be subject to 
     subparagraph (A) in regard to the corrections or updates.
       ``(3) Exemptions.--
       ``(A) In general.--Subsection (b)(2) and any requirements 
     or restrictions placed directly on common carriers under this 
     subsection, including subparagraphs (A) and (B) of paragraph 
     (2), shall not apply to a common carrier that--
       ``(i) is subject to a settlement agreement described in 
     subparagraph (B); or
       ``(ii) if a settlement agreement described in subparagraph 
     (B) to which the common carrier is a party is terminated or 
     otherwise becomes inactive, is administering and enforcing 
     policies and practices throughout the United States that are 
     at least as stringent as the agreement.
       ``(B) Settlement agreement.--A settlement agreement 
     described in this subparagraph--
       ``(i) is a settlement agreement relating to tobacco product 
     deliveries to consumers; and
       ``(ii) includes--

       ``(I) the Assurance of Discontinuance entered into by the 
     Attorney General of New York and DHL Holdings USA, Inc. and 
     DHL Express (USA), Inc. on or about July 1, 2005, the 
     Assurance of Discontinuance entered into by the Attorney 
     General of New York and United Parcel Service, Inc. on or 
     about October 21, 2005, and the Assurance of Compliance 
     entered into by the Attorney General of New York and Federal 
     Express Corporation and FedEx Ground Package Systems, Inc. on 
     or about February 3, 2006, if each of those agreements is 
     honored throughout the United States to block illegal 
     deliveries of cigarettes or smokeless tobacco to consumers; 
     and
       ``(II) any other active agreement between a common carrier 
     and a State that operates throughout the United States to 
     ensure that no deliveries of cigarettes or smokeless tobacco 
     shall be made to consumers or illegally operating Internet or 
     mail-order sellers and that any such deliveries to consumers 
     shall not be made to minors or without payment to the States 
     and localities where the consumers are located of all taxes 
     on the tobacco products.

       ``(4) Shipments from persons on list.--
       ``(A) In general.--If a common carrier or other delivery 
     service delays or interrupts the delivery of a package in the 
     possession of the common carrier or delivery service because 
     the common carrier or delivery service determines or has 
     reason to believe that the person ordering the delivery is on 
     a list described in paragraph (1)(A) and that the package 
     contains cigarettes or smokeless tobacco--
       ``(i) the person ordering the delivery shall be obligated 
     to pay--

       ``(I) the common carrier or other delivery service as if 
     the delivery of the package had been timely completed; and
       ``(II) if the package is not deliverable, any reasonable 
     additional fee or charge levied by the common carrier or 
     other delivery service to cover any extra costs and 
     inconvenience and to serve as a disincentive against such 
     noncomplying delivery orders; and

       ``(ii) if the package is determined not to be deliverable, 
     the common carrier or other delivery service shall offer to 
     provide the package and its contents to a Federal, State, or 
     local law enforcement agency.
       ``(B) Records.--A common carrier or other delivery service 
     shall maintain, for a period of 5 years, any records kept in 
     the ordinary course of business relating to any delivery 
     interrupted under this paragraph and provide that 
     information, upon request, to the Attorney General of the 
     United States or to the attorney general or chief law 
     enforcement official or tax administrator of any State, 
     local, or tribal government.
       ``(C) Confidentiality.--Any person receiving records under 
     subparagraph (B) shall--
       ``(i) use the records solely for the purposes of the 
     enforcement of this Act and the collection of any taxes owed 
     on related sales of cigarettes and smokeless tobacco; and
       ``(ii) keep confidential any personal information in the 
     records not otherwise required for such purposes.
       ``(5) Preemption.--
       ``(A) In general.--No State, local, or tribal government, 
     nor any political authority of 2 or more State, local, or 
     tribal governments, may enact or enforce any law or 
     regulation relating to delivery sales that restricts 
     deliveries of cigarettes or smokeless tobacco to consumers by 
     common carriers or other delivery services on behalf of 
     delivery sellers by--
       ``(i) requiring that the common carrier or other delivery 
     service verify the age or identity of the consumer accepting 
     the delivery by requiring the person who signs to accept 
     delivery of the shipping container to provide proof, in the 
     form of a valid, government-issued identification bearing a 
     photograph of the individual, that the person is at least the 
     minimum age required for the legal sale or purchase of 
     tobacco products, as determined by either State or local law 
     at the place of delivery;
       ``(ii) requiring that the common carrier or other delivery 
     service obtain a signature from the consumer accepting the 
     delivery;
       ``(iii) requiring that the common carrier or other delivery 
     service verify that all applicable taxes have been paid;
       ``(iv) requiring that packages delivered by the common 
     carrier or other delivery service contain any particular 
     labels, notice, or markings; or
       ``(v) prohibiting common carriers or other delivery 
     services from making deliveries on the basis of whether the 
     delivery seller is or is not identified on any list of 
     delivery sellers maintained and distributed by any entity 
     other than the Federal Government.
       ``(B) Relationship to other laws.--Except as provided in 
     subparagraph (C), nothing in this paragraph shall be 
     construed to nullify, expand, restrict, or otherwise amend or 
     modify--
       ``(i) section 14501(c)(1) or 41713(b)(4) of title 49, 
     United States Code;
       ``(ii) any other restrictions in Federal law on the ability 
     of State, local, or tribal governments to regulate common 
     carriers; or
       ``(iii) any provision of State, local, or tribal law 
     regulating common carriers that is described in section 
     14501(c)(2) or 41713(b)(4)(B) of title 49 of the United 
     States Code.
       ``(C) State laws prohibiting delivery sales.--
       ``(i) In general.--Except as provided in clause (ii), 
     nothing in the Prevent All Cigarette Trafficking Act of 2009, 
     the amendments made by that Act, or in any other Federal 
     statute shall be construed to preempt, supersede, or 
     otherwise limit or restrict State laws prohibiting the 
     delivery sale, or the shipment or delivery pursuant to a 
     delivery sale, of cigarettes or other tobacco products to 
     individual consumers or personal residences.
       ``(ii) Exemptions.--No State may enforce against a common 
     carrier a law prohibiting the delivery of cigarettes or other 
     tobacco products to individual consumers or personal 
     residences without proof that the common carrier is not 
     exempt under paragraph (3) of this subsection.
       ``(6) State, local, and tribal additions.--
       ``(A) In general.--Any State, local, or tribal government 
     shall provide the Attorney General of the United States 
     with--
       ``(i) all known names, addresses, website addresses, and 
     other primary contact information of any delivery seller 
     that--

       ``(I) offers for sale or makes sales of cigarettes or 
     smokeless tobacco in or into the State, locality, or tribal 
     land; and
       ``(II) has failed to register with or make reports to the 
     respective tax administrator as required by this Act, or that 
     has been found in a legal proceeding to have otherwise failed 
     to comply with this Act; and

       ``(ii) a list of common carriers and other persons who make 
     deliveries of cigarettes or smokeless tobacco in or into the 
     State, locality, or tribal land.
       ``(B) Updates.--Any government providing a list to the 
     Attorney General of the United States under subparagraph (A) 
     shall also provide updates and corrections every 4 months 
     until such time as the government notifies the Attorney 
     General of the United States in writing that the government 
     no longer desires to submit information to supplement the 
     list described in paragraph (1)(A).
       ``(C) Removal after withdrawal.--Upon receiving written 
     notice that a government no longer desires to submit 
     information under subparagraph (A), the Attorney General of 
     the United States shall remove from the list described in 
     paragraph (1)(A) any persons that are on the list solely 
     because of the prior submissions of the government of the 
     list of the government of noncomplying delivery sellers of 
     cigarettes or smokeless tobacco or a subsequent update or 
     correction by the government.
       ``(7) Deadline to incorporate additions.--The Attorney 
     General of the United States shall--
       ``(A) include any delivery seller identified and submitted 
     by a State, local, or tribal government under paragraph (6) 
     in any list or update that is distributed or made available 
     under paragraph (1) on or after the date that is 30 days 
     after the date on which the information is received by the 
     Attorney General of the United States; and
       ``(B) distribute any list or update described in 
     subparagraph (A) to any common carrier or other person who 
     makes deliveries of cigarettes or smokeless tobacco that has 
     been identified and submitted by a government pursuant to 
     paragraph (6).
       ``(8) Notice to delivery sellers.--Not later than 14 days 
     before including any delivery seller on the initial list 
     described in paragraph (1)(A), or on an update to the list 
     for the first time, the Attorney General of the United States 
     shall make a reasonable attempt to send notice to the 
     delivery seller by letter, electronic mail, or other means 
     that the delivery seller is being placed on the

[[Page S5857]]

     list or update, with that notice citing the relevant 
     provisions of this Act.
       ``(9) Limitations.--
       ``(A) In general.--Any common carrier or other person 
     making a delivery subject to this subsection shall not be 
     required or otherwise obligated to--
       ``(i) determine whether any list distributed or made 
     available under paragraph (1) is complete, accurate, or up-
     to-date;
       ``(ii) determine whether a person ordering a delivery is in 
     compliance with this Act; or
       ``(iii) open or inspect, pursuant to this Act, any package 
     being delivered to determine its contents.
       ``(B) Alternate names.--Any common carrier or other person 
     making a delivery subject to this subsection--
       ``(i) shall not be required to make any inquiries or 
     otherwise determine whether a person ordering a delivery is a 
     delivery seller on the list described in paragraph (1)(A) who 
     is using a different name or address in order to evade the 
     related delivery restrictions; and
       ``(ii) shall not knowingly deliver any packages to 
     consumers for any delivery seller on the list described in 
     paragraph (1)(A) who the common carrier or other delivery 
     service knows is a delivery seller who is on the list and is 
     using a different name or address to evade the delivery 
     restrictions of paragraph (2).
       ``(C) Penalties.--Any common carrier or person in the 
     business of delivering packages on behalf of other persons 
     shall not be subject to any penalty under section 14101(a) of 
     title 49, United States Code, or any other provision of law 
     for--
       ``(i) not making any specific delivery, or any deliveries 
     at all, on behalf of any person on the list described in 
     paragraph (1)(A);
       ``(ii) refusing, as a matter of regular practice and 
     procedure, to make any deliveries, or any deliveries in 
     certain States, of any cigarettes or smokeless tobacco for 
     any person or for any person not in the business of 
     manufacturing, distributing, or selling cigarettes or 
     smokeless tobacco; or
       ``(iii) delaying or not making a delivery for any person 
     because of reasonable efforts to comply with this Act.
       ``(D) Other limits.--Section 2 and subsections (a), (b), 
     (c), and (d) of this section shall not be interpreted to 
     impose any responsibilities, requirements, or liability on 
     common carriers.
       ``(f) Presumption.--For purposes of this Act, a delivery 
     sale shall be deemed to have occurred in the State and place 
     where the buyer obtains personal possession of the cigarettes 
     or smokeless tobacco, and a delivery pursuant to a delivery 
     sale is deemed to have been initiated or ordered by the 
     delivery seller.''.
       (d) Penalties.--The Jenkins Act is amended by striking 
     section 3 and inserting the following:

     ``SEC. 3. PENALTIES.

       ``(a) Criminal Penalties.--
       ``(1) In general.--Except as provided in paragraph (2), 
     whoever knowingly violates this Act shall be imprisoned for 
     not more than 3 years, fined under title 18, United States 
     Code, or both.
       ``(2) Exceptions.--
       ``(A) Governments.--Paragraph (1) shall not apply to a 
     State, local, or tribal government.
       ``(B) Delivery violations.--A common carrier or independent 
     delivery service, or employee of a common carrier or 
     independent delivery service, shall be subject to criminal 
     penalties under paragraph (1) for a violation of section 
     2A(e) only if the violation is committed knowingly--
       ``(i) as consideration for the receipt of, or as 
     consideration for a promise or agreement to pay, anything of 
     pecuniary value; or
       ``(ii) for the purpose of assisting a delivery seller to 
     violate, or otherwise evading compliance with, section 2A.
       ``(b) Civil Penalties.--
       ``(1) In general.--Except as provided in paragraph (3), 
     whoever violates this Act shall be subject to a civil penalty 
     in an amount not to exceed--
       ``(A) in the case of a delivery seller, the greater of--
       ``(i) $5,000 in the case of the first violation, or $10,000 
     for any other violation; or
       ``(ii) for any violation, 2 percent of the gross sales of 
     cigarettes or smokeless tobacco of the delivery seller during 
     the 1-year period ending on the date of the violation.
       ``(B) in the case of a common carrier or other delivery 
     service, $2,500 in the case of a first violation, or $5,000 
     for any violation within 1 year of a prior violation.
       ``(2) Relation to other penalties.--A civil penalty imposed 
     under paragraph (1) for a violation of this Act shall be 
     imposed in addition to any criminal penalty under subsection 
     (a) and any other damages, equitable relief, or injunctive 
     relief awarded by the court, including the payment of any 
     unpaid taxes to the appropriate Federal, State, local, or 
     tribal governments.
       ``(3) Exceptions.--
       ``(A) Delivery violations.--An employee of a common carrier 
     or independent delivery service shall be subject to civil 
     penalties under paragraph (1) for a violation of section 
     2A(e) only if the violation is committed intentionally--
       ``(i) as consideration for the receipt of, or as 
     consideration for a promise or agreement to pay, anything of 
     pecuniary value; or
       ``(ii) for the purpose of assisting a delivery seller to 
     violate, or otherwise evading compliance with, section 2A.
       ``(B) Other limitations.--No common carrier or independent 
     delivery service shall be subject to civil penalties under 
     paragraph (1) for a violation of section 2A(e) if--
       ``(i) the common carrier or independent delivery service 
     has implemented and enforces effective policies and practices 
     for complying with that section; or
       ``(ii) the violation consists of an employee of the common 
     carrier or independent delivery service who physically 
     receives and processes orders, picks up packages, processes 
     packages, or makes deliveries, taking actions that are 
     outside the scope of employment of the employee, or that 
     violate the implemented and enforced policies of the common 
     carrier or independent delivery service described in clause 
     (i).''.
       (e) Enforcement.--The Jenkins Act is amended by striking 
     section 4 and inserting the following:

     ``SEC. 4. ENFORCEMENT.

       ``(a) In General.--The United States district courts shall 
     have jurisdiction to prevent and restrain violations of this 
     Act and to provide other appropriate injunctive or equitable 
     relief, including money damages, for the violations.
       ``(b) Authority of the Attorney General.--The Attorney 
     General of the United States shall administer and enforce 
     this Act.
       ``(c) State, Local, and Tribal Enforcement.--
       ``(1) In general.--
       ``(A) Standing.--A State, through its attorney general, or 
     a local government or Indian tribe that levies a tax subject 
     to section 2A(a)(3), through its chief law enforcement 
     officer, may bring an action in a United States district 
     court to prevent and restrain violations of this Act by any 
     person or to obtain any other appropriate relief from any 
     person for violations of this Act, including civil penalties, 
     money damages, and injunctive or other equitable relief.
       ``(B) Sovereign immunity.--Nothing in this Act shall be 
     deemed to abrogate or constitute a waiver of any sovereign 
     immunity of a State or local government or Indian tribe 
     against any unconsented lawsuit under this Act, or otherwise 
     to restrict, expand, or modify any sovereign immunity of a 
     State or local government or Indian tribe.
       ``(2) Provision of information.--A State, through its 
     attorney general, or a local government or Indian tribe that 
     levies a tax subject to section 2A(a)(3), through its chief 
     law enforcement officer, may provide evidence of a violation 
     of this Act by any person not subject to State, local, or 
     tribal government enforcement actions for violations of this 
     Act to the Attorney General of the United States or a United 
     States attorney, who shall take appropriate actions to 
     enforce this Act.
       ``(3) Use of penalties collected.--
       ``(A) In general.--There is established a separate account 
     in the Treasury known as the `PACT Anti-Trafficking Fund'. 
     Notwithstanding any other provision of law and subject to 
     subparagraph (B), an amount equal to 50 percent of any 
     criminal and civil penalties collected by the Federal 
     Government in enforcing this Act shall be transferred into 
     the PACT Anti-Trafficking Fund and shall be available to the 
     Attorney General of the United States for purposes of 
     enforcing this Act and other laws relating to contraband 
     tobacco products.
       ``(B) Allocation of funds.--Of the amount available to the 
     Attorney General of the United States under subparagraph (A), 
     not less than 50 percent shall be made available only to the 
     agencies and offices within the Department of Justice that 
     were responsible for the enforcement actions in which the 
     penalties concerned were imposed or for any underlying 
     investigations.
       ``(4) Nonexclusivity of remedy.--
       ``(A) In general.--The remedies available under this 
     section and section 3 are in addition to any other remedies 
     available under Federal, State, local, tribal, or other law.
       ``(B) State court proceedings.--Nothing in this Act shall 
     be construed to expand, restrict, or otherwise modify any 
     right of an authorized State official to proceed in State 
     court, or take other enforcement actions, on the basis of an 
     alleged violation of State or other law.
       ``(C) Tribal court proceedings.--Nothing in this Act shall 
     be construed to expand, restrict, or otherwise modify any 
     right of an authorized Indian tribal government official to 
     proceed in tribal court, or take other enforcement actions, 
     on the basis of an alleged violation of tribal law.
       ``(D) Local government enforcement.--Nothing in this Act 
     shall be construed to expand, restrict, or otherwise modify 
     any right of an authorized local government official to 
     proceed in State court, or take other enforcement actions, on 
     the basis of an alleged violation of local or other law.
       ``(d) Persons Dealing in Tobacco Products.--Any person who 
     holds a permit under section 5712 of the Internal Revenue 
     Code of 1986 (regarding permitting of manufacturers and 
     importers of tobacco products and export warehouse 
     proprietors) may bring an action in an appropriate United 
     States district court to prevent and restrain violations of 
     this Act by any person other than a State, local, or tribal 
     government.
       ``(e) Notice.--
       ``(1) Persons dealing in tobacco products.--Any person who 
     commences a civil action under subsection (d) shall inform 
     the Attorney General of the United States of the action.

[[Page S5858]]

       ``(2) State, local, and tribal actions.--It is the sense of 
     Congress that the attorney general of any State, or chief law 
     enforcement officer of any locality or tribe, that commences 
     a civil action under this section should inform the Attorney 
     General of the United States of the action.
       ``(f) Public Notice.--
       ``(1) In general.--The Attorney General of the United 
     States shall make available to the public, by posting 
     information on the Internet and by other appropriate means, 
     information regarding all enforcement actions brought by the 
     United States, or reported to the Attorney General of the 
     United States, under this section, including information 
     regarding the resolution of the enforcement actions and how 
     the Attorney General of the United States has responded to 
     referrals of evidence of violations pursuant to subsection 
     (c)(2).
       ``(2) Reports to congress.--Not later than 1 year after the 
     date of enactment of the Prevent All Cigarette Trafficking 
     Act of 2009, and every year thereafter until the date that is 
     5 years after such date of enactment, the Attorney General of 
     the United States shall submit to Congress a report 
     containing the information described in paragraph (1).''.

     SEC. 3. TREATMENT OF CIGARETTES AND SMOKELESS TOBACCO AS 
                   NONMAILABLE MATTER.

       (a) In General.--Chapter 83 of title 18, United States 
     Code, is amended by inserting after section 1716D the 
     following:

     ``Sec. 1716E. Tobacco products as nonmailable

       ``(a) Prohibition.--
       ``(1) In general.--All cigarettes and smokeless tobacco (as 
     those terms are defined in section 1 of the Act of October 
     19, 1949, commonly referred to as the Jenkins Act) are 
     nonmailable and shall not be deposited in or carried through 
     the mails. The United States Postal Service shall not accept 
     for delivery or transmit through the mails any package that 
     it knows or has reasonable cause to believe contains any 
     cigarettes or smokeless tobacco made nonmailable by this 
     paragraph.
       ``(2) Reasonable cause.--For the purposes of this 
     subsection reasonable cause includes--
       ``(A) a statement on a publicly available website, or an 
     advertisement, by any person that the person will mail matter 
     which is nonmailable under this section in return for 
     payment; or
       ``(B) the fact that the person is on the list created under 
     section 2A(e) of the Jenkins Act.
       ``(b) Exceptions.--
       ``(1) Cigars.--Subsection (a) shall not apply to cigars (as 
     defined in section 5702(a) of the Internal Revenue Code of 
     1986).
       ``(2) Geographic exception.--Subsection (a) shall not apply 
     to mailings within the State of Alaska or within the State of 
     Hawaii.
       ``(3) Business purposes.--
       ``(A) In general.--Subsection (a) shall not apply to 
     tobacco products mailed only--
       ``(i) for business purposes between legally operating 
     businesses that have all applicable State and Federal 
     Government licenses or permits and are engaged in tobacco 
     product manufacturing, distribution, wholesale, export, 
     import, testing, investigation, or research; or
       ``(ii) for regulatory purposes between any business 
     described in clause (i) and an agency of the Federal 
     Government or a State government.
       ``(B) Rules.--
       ``(i) In general.--Not later than 180 days after the date 
     of enactment of the Prevent All Cigarette Trafficking Act of 
     2009, the Postmaster General shall issue a final rule which 
     shall establish the standards and requirements that apply to 
     all mailings described in subparagraph (A).
       ``(ii) Contents.--The final rule issued under clause (i) 
     shall require--

       ``(I) the United States Postal Service to verify that any 
     person submitting an otherwise nonmailable tobacco product 
     into the mails as authorized under this paragraph is a 
     business or government agency permitted to make a mailing 
     under this paragraph;
       ``(II) the United States Postal Service to ensure that any 
     recipient of an otherwise nonmailable tobacco product sent 
     through the mails under this paragraph is a business or 
     government agency that may lawfully receive the product;
       ``(III) that any mailing described in subparagraph (A) 
     shall be sent through the systems of the United States Postal 
     Service that provide for the tracking and confirmation of the 
     delivery;
       ``(IV) that the identity of the business or government 
     entity submitting the mailing containing otherwise 
     nonmailable tobacco products for delivery and the identity of 
     the business or government entity receiving the mailing are 
     clearly set forth on the package;
       ``(V) the United States Postal Service to maintain 
     identifying information described in subclause (IV) during 
     the 3-year period beginning on the date of the mailing and 
     make the information available to the Postal Service, the 
     Attorney General of the United States, and to persons 
     eligible to bring enforcement actions under section 3(d) of 
     the Prevent All Cigarette Trafficking Act of 2009;
       ``(VI) that any mailing described in subparagraph (A) be 
     marked with a United States Postal Service label or marking 
     that makes it clear to employees of the United States Postal 
     Service that it is a permitted mailing of otherwise 
     nonmailable tobacco products that may be delivered only to a 
     permitted government agency or business and may not be 
     delivered to any residence or individual person; and
       ``(VII) that any mailing described in subparagraph (A) be 
     delivered only to a verified employee of the recipient 
     business or government agency, who is not a minor and who 
     shall be required to sign for the mailing.

       ``(C) Definition.--In this paragraph, the term `minor' 
     means an individual who is less than the minimum age required 
     for the legal sale or purchase of tobacco products as 
     determined by applicable law at the place the individual is 
     located.
       ``(4) Certain individuals.--
       ``(A) In general.--Subsection (a) shall not apply to 
     tobacco products mailed by individuals who are not minors for 
     noncommercial purposes, including the return of a damaged or 
     unacceptable tobacco product to the manufacturer.
       ``(B) Rules.--
       ``(i) In general.--Not later than 180 days after the date 
     of enactment of the Prevent All Cigarette Trafficking Act of 
     2009, the Postmaster General shall issue a final rule which 
     shall establish the standards and requirements that apply to 
     all mailings described in subparagraph (A).
       ``(ii) Contents.--The final rule issued under clause (i) 
     shall require--

       ``(I) the United States Postal Service to verify that any 
     person submitting an otherwise nonmailable tobacco product 
     into the mails as authorized under this paragraph is the 
     individual identified on the return address label of the 
     package and is not a minor;
       ``(II) for a mailing to an individual, the United States 
     Postal Service to require the person submitting the otherwise 
     nonmailable tobacco product into the mails as authorized by 
     this paragraph to affirm that the recipient is not a minor;
       ``(III) that any package mailed under this paragraph shall 
     weigh not more than 10 ounces;
       ``(IV) that any mailing described in subparagraph (A) shall 
     be sent through the systems of the United States Postal 
     Service that provide for the tracking and confirmation of the 
     delivery;
       ``(V) that a mailing described in subparagraph (A) shall 
     not be delivered or placed in the possession of any 
     individual who has not been verified as not being a minor;
       ``(VI) for a mailing described in subparagraph (A) to an 
     individual, that the United States Postal Service shall 
     deliver the package only to a recipient who is verified not 
     to be a minor at the recipient address or transfer it for 
     delivery to an Air/Army Postal Office or Fleet Postal Office 
     number designated in the recipient address; and
       ``(VII) that no person may initiate more than 10 mailings 
     described in subparagraph (A) during any 30-day period.

       ``(C) Definition.--In this paragraph, the term `minor' 
     means an individual who is less than the minimum age required 
     for the legal sale or purchase of tobacco products as 
     determined by applicable law at the place the individual is 
     located.
       ``(5) Exception for mailings for consumer testing by 
     manufacturers.--
       ``(A) In general.--Subject to subparagraph (B), subsection 
     (a) shall not preclude a legally operating cigarette 
     manufacturer or a legally authorized agent of a legally 
     operating cigarette manufacturer from using the United States 
     Postal Service to mail cigarettes to verified adult smoker 
     solely for consumer testing purposes, if--
       ``(i) the cigarette manufacturer has a permit, in good 
     standing, issued under section 5713 of the Internal Revenue 
     Code of 1986;
       ``(ii) the package of cigarettes mailed under this 
     paragraph contains not more than 12 packs of cigarettes (240 
     cigarettes);
       ``(iii) the recipient does not receive more than 1 package 
     of cigarettes from any 1 cigarette manufacturer under this 
     paragraph during any 30-day period;
       ``(iv) all taxes on the cigarettes mailed under this 
     paragraph levied by the State and locality of delivery are 
     paid to the State and locality before delivery, and tax 
     stamps or other tax-payment indicia are affixed to the 
     cigarettes as required by law; and
       ``(v)(I) the recipient has not made any payments of any 
     kind in exchange for receiving the cigarettes;
       ``(II) the recipient is paid a fee by the manufacturer or 
     agent of the manufacturer for participation in consumer 
     product tests; and
       ``(III) the recipient, in connection with the tests, 
     evaluates the cigarettes and provides feedback to the 
     manufacturer or agent.
       ``(B) Limitations.--Subparagraph (A) shall not--
       ``(i) permit a mailing of cigarettes to an individual 
     located in any State that prohibits the delivery or shipment 
     of cigarettes to individuals in the State, or preempt, limit, 
     or otherwise affect any related State laws; or
       ``(ii) permit a manufacturer, directly or through a legally 
     authorized agent, to mail cigarettes in any calendar year in 
     a total amount greater than 1 percent of the total cigarette 
     sales of the manufacturer in the United States during the 
     calendar year before the date of the mailing.
       ``(C) Rules.--
       ``(i) In general.--Not later than 180 days after the date 
     of enactment of the Prevent All Cigarette Trafficking Act of 
     2009, the Postmaster General shall issue a final rule which 
     shall establish the standards and requirements that apply to 
     all mailings described in subparagraph (A).
       ``(ii) Contents.--The final rule issued under clause (i) 
     shall require--

[[Page S5859]]

       ``(I) the United States Postal Service to verify that any 
     person submitting a tobacco product into the mails under this 
     paragraph is a legally operating cigarette manufacturer 
     permitted to make a mailing under this paragraph, or an agent 
     legally authorized by the legally operating cigarette 
     manufacturer to submit the tobacco product into the mails on 
     behalf of the manufacturer;
       ``(II) the legally operating cigarette manufacturer 
     submitting the cigarettes into the mails under this paragraph 
     to affirm that--

       ``(aa) the manufacturer or the legally authorized agent of 
     the manufacturer has verified that the recipient is an adult 
     established smoker;
       ``(bb) the recipient has not made any payment for the 
     cigarettes;
       ``(cc) the recipient has signed a written statement that is 
     in effect indicating that the recipient wishes to receive the 
     mailings; and
       ``(dd) the manufacturer or the legally authorized agent of 
     the manufacturer has offered the opportunity for the 
     recipient to withdraw the written statement described in item 
     (cc) not less frequently than once in every 3-month period;

       ``(III) the legally operating cigarette manufacturer or the 
     legally authorized agent of the manufacturer submitting the 
     cigarettes into the mails under this paragraph to affirm that 
     any package mailed under this paragraph contains not more 
     than 12 packs of cigarettes (240 cigarettes) on which all 
     taxes levied on the cigarettes by the State and locality of 
     delivery have been paid and all related State tax stamps or 
     other tax-payment indicia have been applied;
       ``(IV) that any mailing described in subparagraph (A) shall 
     be sent through the systems of the United States Postal 
     Service that provide for the tracking and confirmation of the 
     delivery;
       ``(V) the United States Postal Service to maintain records 
     relating to a mailing described in subparagraph (A) during 
     the 3-year period beginning on the date of the mailing and 
     make the information available to persons enforcing this 
     section;
       ``(VI) that any mailing described in subparagraph (A) be 
     marked with a United States Postal Service label or marking 
     that makes it clear to employees of the United States Postal 
     Service that it is a permitted mailing of otherwise 
     nonmailable tobacco products that may be delivered only to 
     the named recipient after verifying that the recipient is an 
     adult; and
       ``(VII) the United States Postal Service shall deliver a 
     mailing described in subparagraph (A) only to the named 
     recipient and only after verifying that the recipient is an 
     adult.

       ``(D) Definitions.--In this paragraph--
       ``(i) the term `adult' means an individual who is not less 
     than 21 years of age; and
       ``(ii) the term `consumer testing' means testing limited to 
     formal data collection and analysis for the specific purpose 
     of evaluating the product for quality assurance and 
     benchmarking purposes of cigarette brands or sub-brands among 
     existing adult smokers.
       ``(6) Federal government agencies.--An agency of the 
     Federal Government involved in the consumer testing of 
     tobacco products solely for public health purposes may mail 
     cigarettes under the same requirements, restrictions, and 
     rules and procedures that apply to consumer testing mailings 
     of cigarettes by manufacturers under paragraph (5), except 
     that the agency shall not be required to pay the recipients 
     for participating in the consumer testing.
       ``(c) Seizure and Forfeiture.--Any cigarettes or smokeless 
     tobacco made nonmailable by this subsection that are 
     deposited in the mails shall be subject to seizure and 
     forfeiture, pursuant to the procedures set forth in chapter 
     46 of this title. Any tobacco products seized and forfeited 
     under this subsection shall be destroyed or retained by the 
     Federal Government for the detection or prosecution of crimes 
     or related investigations and then destroyed.
       ``(d) Additional Penalties.--In addition to any other fines 
     and penalties under this title for violations of this 
     section, any person violating this section shall be subject 
     to an additional civil penalty in the amount equal to 10 
     times the retail value of the nonmailable cigarettes or 
     smokeless tobacco, including all Federal, State, and local 
     taxes.
       ``(e) Criminal Penalty.--Whoever knowingly deposits for 
     mailing or delivery, or knowingly causes to be delivered by 
     mail, according to the direction thereon, or at any place at 
     which it is directed to be delivered by the person to whom it 
     is addressed, anything that is nonmailable matter under this 
     section shall be fined under this title, imprisoned not more 
     than 1 year, or both.
       ``(f) Use of Penalties.--There is established a separate 
     account in the Treasury, to be known as the `PACT Postal 
     Service Fund'. Notwithstanding any other provision of law, an 
     amount equal to 50 percent of any criminal fines, civil 
     penalties, or other monetary penalties collected by the 
     Federal Government in enforcing this section shall be 
     transferred into the PACT Postal Service Fund and shall be 
     available to the Postmaster General for the purpose of 
     enforcing this subsection.
       ``(g) Coordination of Efforts.--The Postmaster General 
     shall cooperate and coordinate efforts to enforce this 
     section with related enforcement activities of any other 
     Federal agency or agency of any State, local, or tribal 
     government, whenever appropriate.
       ``(h) Actions by State, Local, or Tribal Governments 
     Relating to Certain Tobacco Products.--
       ``(1) In general.--A State, through its attorney general, 
     or a local government or Indian tribe that levies an excise 
     tax on tobacco products, through its chief law enforcement 
     officer, may in a civil action in a United States district 
     court obtain appropriate relief with respect to a violation 
     of this section. Appropriate relief includes injunctive and 
     equitable relief and damages equal to the amount of unpaid 
     taxes on tobacco products mailed in violation of this section 
     to addressees in that State, locality, or tribal land.
       ``(2) Sovereign immunity.--Nothing in this subsection shall 
     be deemed to abrogate or constitute a waiver of any sovereign 
     immunity of a State or local government or Indian tribe 
     against any unconsented lawsuit under paragraph (1), or 
     otherwise to restrict, expand, or modify any sovereign 
     immunity of a State or local government or Indian tribe.
       ``(3) Attorney general referral.--A State, through its 
     attorney general, or a local government or Indian tribe that 
     levies an excise tax on tobacco products, through its chief 
     law enforcement officer, may provide evidence of a violation 
     of this section for commercial purposes by any person not 
     subject to State, local, or tribal government enforcement 
     actions for violations of this section to the Attorney 
     General of the United States, who shall take appropriate 
     actions to enforce this section.
       ``(4) Nonexclusivity of remedies.--The remedies available 
     under this subsection are in addition to any other remedies 
     available under Federal, State, local, tribal, or other law. 
     Nothing in this subsection shall be construed to expand, 
     restrict, or otherwise modify any right of an authorized 
     State, local, or tribal government official to proceed in a 
     State, tribal, or other appropriate court, or take other 
     enforcement actions, on the basis of an alleged violation of 
     State, local, tribal, or other law.
       ``(5) Other enforcement actions.--Nothing in this 
     subsection shall be construed to prohibit an authorized State 
     official from proceeding in State court on the basis of an 
     alleged violation of any general civil or criminal statute of 
     the State.
       ``(i) Definition.--In this section, the term `State' has 
     the meaning given that term in section 1716(k).''.
       (b) Clerical Amendment.--The table of sections for chapter 
     83 of title 18 is amended by inserting after the item 
     relating to section 1716D the following:

``1716E. Tobacco products as nonmailable.''.

     SEC. 4. COMPLIANCE WITH MODEL STATUTE OR QUALIFYING STATUTE.

       (a) In General.--A Tobacco Product Manufacturer or importer 
     may not sell in, deliver to, or place for delivery sale, or 
     cause to be sold in, delivered to, or placed for delivery 
     sale in a State that is a party to the Master Settlement 
     Agreement, any cigarette manufactured by a Tobacco Product 
     Manufacturer that is not in full compliance with the terms of 
     the Model Statute or Qualifying Statute enacted by the State 
     requiring funds to be placed into a qualified escrow account 
     under specified conditions, and with any regulations 
     promulgated pursuant to the statute.
       (b) Jurisdiction To Prevent and Restrain Violations.--
       (1) In general.--The United States district courts shall 
     have jurisdiction to prevent and restrain violations of 
     subsection (a) in accordance with this subsection.
       (2) Initiation of action.--A State, through its attorney 
     general, may bring an action in an appropriate United States 
     district court to prevent and restrain violations of 
     subsection (a) by any person.
       (3) Attorney fees.--In any action under paragraph (2), a 
     State, through its attorney general, shall be entitled to 
     reasonable attorney fees from a person found to have 
     knowingly violated subsection (a).
       (4) Nonexclusivity of remedies.--The remedy available under 
     paragraph (2) is in addition to any other remedies available 
     under Federal, State, or other law. No provision of this Act 
     or any other Federal law shall be held or construed to 
     prohibit or preempt the Master Settlement Agreement, the 
     Model Statute (as defined in the Master Settlement 
     Agreement), any legislation amending or complementary to the 
     Model Statute in effect as of June 1, 2006, or any 
     legislation substantially similar to such existing, amending, 
     or complementary legislation enacted after the date of 
     enactment of this Act.
       (5) Other enforcement actions.--Nothing in this subsection 
     shall be construed to prohibit an authorized State official 
     from proceeding in State court or taking other enforcement 
     actions on the basis of an alleged violation of State or 
     other law.
       (6) Authority of the attorney general.--The Attorney 
     General of the United States may bring an action in an 
     appropriate United States district court to prevent and 
     restrain violations of subsection (a) by any person.
       (c) Definitions.--In this section the following definitions 
     apply:
       (1) Delivery sale.--The term ``delivery sale'' means any 
     sale of cigarettes or smokeless tobacco to a consumer if--
       (A) the consumer submits the order for the sale by means of 
     a telephone or other method of voice transmission, the mails, 
     or the Internet or other online service, or the seller is 
     otherwise not in the physical presence of the buyer when the 
     request for purchase or order is made; or
       (B) the cigarettes or smokeless tobacco are delivered to 
     the buyer by common carrier,

[[Page S5860]]

     private delivery service, or other method of remote delivery, 
     or the seller is not in the physical presence of the buyer 
     when the buyer obtains possession of the cigarettes or 
     smokeless tobacco.
       (2) Importer.--The term ``importer'' means each of the 
     following:
       (A) Shipping or consigning.--Any person in the United 
     States to whom nontaxpaid tobacco products manufactured in a 
     foreign country, Puerto Rico, the Virgin Islands, or a 
     possession of the United States are shipped or consigned.
       (B) Manufacturing warehouses.--Any person who removes 
     cigars or cigarettes for sale or consumption in the United 
     States from a customs-bonded manufacturing warehouse.
       (C) Unlawful importing.--Any person who smuggles or 
     otherwise unlawfully brings tobacco products into the United 
     States.
       (3) Master settlement agreement.--The term ``Master 
     Settlement Agreement'' means the agreement executed November 
     23, 1998, between the attorneys general of 46 States, the 
     District of Columbia, the Commonwealth of Puerto Rico, and 4 
     territories of the United States and certain tobacco 
     manufacturers.
       (4) Model statute; qualifying statute.--The terms ``Model 
     Statute'' and ``Qualifying Statute'' means a statute as 
     defined in section IX(d)(2)(e) of the Master Settlement 
     Agreement.
       (5) Tobacco product manufacturer.--The term ``Tobacco 
     Product Manufacturer'' has the meaning given that term in 
     section II(uu) of the Master Settlement Agreement.

     SEC. 5. INSPECTION BY BUREAU OF ALCOHOL, TOBACCO, FIREARMS, 
                   AND EXPLOSIVES OF RECORDS OF CERTAIN CIGARETTE 
                   AND SMOKELESS TOBACCO SELLERS; CIVIL PENALTY.

       Section 2343(c) of title 18, United States Code, is amended 
     to read as follows:
       ``(c)(1) Any officer of the Bureau of Alcohol, Tobacco, 
     Firearms, and Explosives may, during normal business hours, 
     enter the premises of any person described in subsection (a) 
     or (b) for the purposes of inspecting--
       ``(A) any records or information required to be maintained 
     by the person under this chapter; or
       ``(B) any cigarettes or smokeless tobacco kept or stored by 
     the person at the premises.
       ``(2) The district courts of the United States shall have 
     the authority in a civil action under this subsection to 
     compel inspections authorized by paragraph (1).
       ``(3) Whoever denies access to an officer under paragraph 
     (1), or who fails to comply with an order issued under 
     paragraph (2), shall be subject to a civil penalty in an 
     amount not to exceed $10,000.''.

     SEC. 6. EXCLUSIONS REGARDING INDIAN TRIBES AND TRIBAL 
                   MATTERS.

       (a) In General.--Nothing in this Act or the amendments made 
     by this Act shall be construed to amend, modify, or otherwise 
     affect--
       (1) any agreements, compacts, or other intergovernmental 
     arrangements between any State or local government and any 
     government of an Indian tribe (as that term is defined in 
     section 4(e) of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450b(e)) relating to the collection 
     of taxes on cigarettes or smokeless tobacco sold in Indian 
     country;
       (2) any State laws that authorize or otherwise pertain to 
     any such intergovernmental arrangements or create special 
     rules or procedures for the collection of State, local, or 
     tribal taxes on cigarettes or smokeless tobacco sold in 
     Indian country;
       (3) any limitations under Federal or State law, including 
     Federal common law and treaties, on State, local, and tribal 
     tax and regulatory authority with respect to the sale, use, 
     or distribution of cigarettes and smokeless tobacco by or to 
     Indian tribes, tribal members, tribal enterprises, or in 
     Indian country;
       (4) any Federal law, including Federal common law and 
     treaties, regarding State jurisdiction, or lack thereof, over 
     any tribe, tribal members, tribal enterprises, tribal 
     reservations, or other lands held by the United States in 
     trust for one or more Indian tribes; or
       (5) any State or local government authority to bring 
     enforcement actions against persons located in Indian 
     country.
       (b) Coordination of Law Enforcement.--Nothing in this Act 
     or the amendments made by this Act shall be construed to 
     inhibit or otherwise affect any coordinated law enforcement 
     effort by 1 or more States or other jurisdictions, including 
     Indian tribes, through interstate compact or otherwise, 
     that--
       (1) provides for the administration of tobacco product laws 
     or laws pertaining to interstate sales or other sales of 
     tobacco products;
       (2) provides for the seizure of tobacco products or other 
     property related to a violation of such laws; or
       (3) establishes cooperative programs for the administration 
     of such laws.
       (c) Treatment of State and Local Governments.--Nothing in 
     this Act or the amendments made by this Act shall be 
     construed to authorize, deputize, or commission States or 
     local governments as instrumentalities of the United States.
       (d) Enforcement Within Indian Country.--Nothing in this Act 
     or the amendments made by this Act shall prohibit, limit, or 
     restrict enforcement by the Attorney General of the United 
     States of this Act or an amendment made by this Act within 
     Indian country.
       (e) Ambiguity.--Any ambiguity between the language of this 
     section or its application and any other provision of this 
     Act shall be resolved in favor of this section.
       (f) Definitions.--In this section--
       (1) the term ``Indian country'' has the meaning given that 
     term in section 1 of the Jenkins Act, as amended by this Act; 
     and
       (2) the term ``tribal enterprise'' means any business 
     enterprise, regardless of whether incorporated or 
     unincorporated under Federal or tribal law, of an Indian 
     tribe or group of Indian tribes.

     SEC. 7. ENHANCED CONTRABAND TOBACCO ENFORCEMENT.

       (a) Requirements.--The Director of the Bureau of Alcohol, 
     Tobacco, Firearms, and Explosives shall--
       (1) not later than the end of the 3-year period beginning 
     on the effective date of this Act, create a regional 
     contraband tobacco trafficking team in each of New York, New 
     York, the District of Columbia, Detroit, Michigan, Los 
     Angeles, California, Seattle, Washington, and Miami, Florida;
       (2) create a Tobacco Intelligence Center to oversee 
     investigations and monitor and coordinate ongoing 
     investigations and to serve as the coordinator for all 
     ongoing tobacco diversion investigations within the Bureau of 
     Alcohol, Tobacco, Firearms, and Explosives, in the United 
     States and, where applicable, with law enforcement 
     organizations around the world;
       (3) establish a covert national warehouse for undercover 
     operations; and
       (4) create a computer database that will track and analyze 
     information from retail sellers of tobacco products that sell 
     through the Internet or by mail order or make other non-face-
     to-face sales.
       (b) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out subsection (a) $8,500,000 for 
     each of fiscal years 2010 through 2014.

     SEC. 8. EFFECTIVE DATE.

       (a) In General.--Except as provided in subsection (b), this 
     Act shall take effect on the date that is 90 days after the 
     date of enactment of this Act.
       (b) BATFE Authority.--The amendments made by section 5 
     shall take effect on the date of enactment of this Act.

     SEC. 9. SEVERABILITY.

       If any provision of this Act, or any amendment made by this 
     Act, or the application thereof to any person or 
     circumstance, is held invalid, the remainder of the Act and 
     the application of the Act to any other person or 
     circumstance shall not be affected thereby.

     SEC. 10. SENSE OF CONGRESS CONCERNING THE PRECEDENTIAL EFFECT 
                   OF THIS ACT.

       It is the sense of Congress that unique harms are 
     associated with online cigarette sales, including problems 
     with verifying the ages of consumers in the digital market 
     and the long-term health problems associated with the use of 
     certain tobacco products. This Act was enacted recognizing 
     the longstanding interest of Congress in urging compliance 
     with States' laws regulating remote sales of certain tobacco 
     products to citizens of those States, including the passage 
     of the Jenkins Act over 50 years ago, which established 
     reporting requirements for out-of-State companies that sell 
     certain tobacco products to citizens of the taxing States, 
     and which gave authority to the Department of Justice and the 
     Bureau of Alcohol, Tobacco, Firearms, and Explosives to 
     enforce the Jenkins Act. In light of the unique harms and 
     circumstances surrounding the online sale of certain tobacco 
     products, this Act is intended to help collect cigarette 
     excise taxes, to stop tobacco sales to underage youth, and to 
     help the States enforce their laws that target the online 
     sales of certain tobacco products only. This Act is in no way 
     meant to create a precedent regarding the collection of State 
     sales or use taxes by, or the validity of efforts to impose 
     other types of taxes on, out-of-State entities that do not 
     have a physical presence within the taxing State.
                                 ______
                                 
      By Mr. GRASSLEY (for himself, Mrs. McCaskill, Mr. Bond, and Mr. 
        Thune):
  S. 1148. A bill to amend the Clean Air Act to modify a provision 
relating to the renewable fuel program; to the Committee on Environment 
and Public Works.
  Mr. GRASSLEY. Mr. President, I am pleased to be joined today in 
introducing commonsense legislation with Senators McCaskill and Bond. 
The Renewable Fuel Standard Improvement Act, seeks to improve a number 
of provisions included in the expanded Renewable Fuels Standard that 
was enacted in the Energy Independence and Security Act of 2007, EISA.
  Just a week ago, the Chairman of the House Agriculture Committee, 
Representative Collin Peterson, introduced this legislation in the 
House of Representatives. It now has more than 44 bipartisan 
cosponsors. Because Chairman Peterson crafted such thoughtful 
modifications to the Renewable Fuel Standard, I want to give my Senate 
colleagues an opportunity to consider the bill. So, today I am 
introducing companion legislation in the Senate.

[[Page S5861]]

  A component of the new Renewable Fuels Standard was a requirement 
that various biofuels meet specified life-cycle greenhouse gas emission 
reduction targets. The law specified that lifecycle greenhouse gas 
emissions are to include direct emissions and significant indirect 
emissions from indirect land use changes. In the Notice of Proposed 
Rulemaking released by the Environmental Protection Agency earlier this 
month, the EPA relies on incomplete science and inaccurate assumptions 
to penalize U.S. biofuels for so-called ``indirect land use changes.'' 
So, this bill ensures that the greenhouse gas calculations are based on 
proven science by removing the requirement to include indirect land use 
changes.
  The bill also includes a number of other commonsense fixes to the 
expanded Renewable Fuels Standard. Under EISA, the life-cycle 
greenhouse gas reduction requirements do not apply to corn ethanol 
plants that were in operation or under construction prior to the date 
of enactment. This grandfather provision does not apply to biodiesel 
facilities, however. The legislation I am introducing today would 
extend the same grandfathered treatment to biodiesel facilities.
  Finally, the bill includes a more inclusive definition of renewable 
biomass, and it expands the role of the U.S. Departments of Agriculture 
and Energy in administering the program.
  This bill goes a long way to rectifying a few provisions that are 
undermining and harming our efforts toward energy independence. I do 
not think it makes sense to impose hurdles on our domestic renewable 
fuels industry, particularly if it prolongs our dependence on dirtier 
fossil fuels, or increases our dependence on energy from countries like 
Iran and Venezuela.
  I would like to thank the cosponsors for their support. I look 
forward to Senate consideration of this important legislation.
                                 ______
                                 
      By Mr. REID (for Mr. Rockefeller):
  S. 1149. A bill to eliminate annual and lifetime aggregate limits 
imposed by health plans; to the Committee on Health, Education, Labor, 
and Pensions.
  Mr. ROCKEFELLER. Mr. President, I rise today to introduce the Annual 
and Lifetime Health Care Limit Elimination Act of 2009, legislation 
that would prohibit insurance companies from imposing any annual or 
lifetime limit on any individual or group health insurance policy, thus 
providing continuity and affordability of health care coverage for 
those with serious chronic conditions.
  Each year, thousands of insured Americans face daunting medical 
expenses and challenges when they reach the annual or lifetime limit on 
their individual or employer-sponsored health insurance plan. Once a 
beneficiary's medical costs have exceeded the annual or lifetime limit 
of their plan, the insurance company no longer pays for the medical 
costs incurred by that individual.
  In April, I held a roundtable discussion on health care in Raleigh 
County. There, I met a woman who had myelodysplastic syndrome, which is 
a non-curable pre-leukemia type disease. Unfortunately, her husband's 
insurance policy had a lifetime limit of $300,000, which she had 
reached. Another young West Virginian, born with serious congenital 
heart defects, reached the $1 million limit on his mother's insurance 
policy within the first nine months of his life. The limits on their 
health insurance plans have left these families struggling to find a 
way to pay for the expensive and life-sustaining treatments their loved 
ones desperately need.
  Unfortunately, these two West Virginia families are not alone. In 
2007, it was estimated that 55 percent of all people who obtain health 
benefits from their employer have some type of lifetime limit on their 
plan, an increase of approximately 4 percent since 2004. More than 23 
percent of people have health insurance plans that impose limits of $2 
million or less. Also, some health insurance policies renew less 
frequently than annually and contain annual limits to reduce the 
medical expenses paid by insurance companies. It is estimated that 
approximately 20,000 to 25,000 people no longer have health care 
benefits through their employers because of lifetime limits on their 
employer-sponsored health care plans.
  When individuals with serious chronic conditions--such as transplant 
recipients, patients living with hemophilia, and newborns with life-
threatening illnesses--hit the annual or lifetime limits on their 
policies, they are often left with very few options to meet their 
health care needs. Individuals and families that can afford it can try 
to pay for their health care costs completely out-of-pocket. However, 
this is rarely financially feasible; therefore, many people are forced 
to leave good, stable jobs and seek different employment in an effort 
to obtain new employer-sponsored coverage. Unfortunately, new enrollees 
are often subject to a waiting period for coverage if there was any 
break in their previous health care coverage.
  Should an individual try to find health insurance in the individual 
market, coverage is likely to be prohibitively expensive. More often 
then not, these individuals are denied coverage altogether because of 
the insurer's pre-existing condition exclusion. Annual or lifetime 
limits can force people to turn to public programs such as Medicaid, or 
spend down their savings to meet the financial restrictions of the 
program. Others are forced to forgo treatment altogether, which can 
lead to serious complications and greater long-term health care costs.
  It is time to stop health insurance companies from imposing annual or 
lifetime limits on health insurance policies. The beneficiaries 
affected by these limits have paid their premiums, deductibles, and 
copays faithfully, only to lose access to life-saving treatment when 
they need care the most. This is unacceptable and I encourage my 
colleagues to join me in supporting the Annual and Lifetime Health Care 
Limit Elimination Act.
  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. 1149

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Annual and Lifetime Health 
     Care Limit Elimination Act of 2009''.

     SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY 
                   ACT OF 1974.

       (a) In General.--Subpart B of part 7 of subtitle B of title 
     I of the Employee Retirement Income Security Act of 1974 (29 
     U.S.C. 1185 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 715. ELIMINATION OF ANNUAL OR LIFETIME AGGREGATE 
                   LIMITS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer providing health insurance coverage in 
     connection with a group health plan, may not impose an 
     aggregate dollar annual or lifetime limit with respect to 
     benefits payable under the plan or coverage.
       ``(b) Definition.--In this section, the term `aggregate 
     dollar annual or lifetime limit' means, with respect to 
     benefits under a group health plan or health insurance 
     coverage, a dollar limitation on the total amount that may be 
     paid with respect to such benefits under the plan or health 
     insurance coverage with respect to an individual or other 
     coverage unit on an annual or lifetime basis.''.
       (b) Clerical Amendment.--The table of contents in section 1 
     of such Act, is amended by inserting after the item relating 
     to section 714 the following new item:

``Sec. 715. Elimination of annual or lifetime aggregate limits.''.

       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on or after 
     the date that is 1 year after the date of enactment of this 
     Act.

     SEC. 3. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING 
                   TO THE GROUP MARKET.

       (a) In General.--Subpart 2 of part A of title XXVII of the 
     Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is 
     amended by adding at the end the following:

     ``SEC. 2708. ELIMINATION OF ANNUAL OR LIFETIME AGGREGATE 
                   LIMITS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer providing health insurance coverage in 
     connection with a group health plan, may not impose an 
     aggregate dollar annual or lifetime limit with respect to 
     benefits payable under the plan or coverage.
       ``(b) Definition.--In this section, the term `aggregate 
     dollar annual or lifetime limit' means, with respect to 
     benefits under a group health plan or health insurance 
     coverage, a dollar limitation on the total amount that may be 
     paid with respect to such benefits under the plan or health 
     insurance coverage with respect to an individual

[[Page S5862]]

     or other coverage unit on an annual or lifetime basis.''.
       (b) Individual Market.--Subpart 2 of part B of title XXVII 
     of the Public Health Service Act (42 U.S.C. 300gg-51 et seq.) 
     is amended by adding at the end the following:

     ``SEC. 2754. ELIMINATION OF ANNUAL OR LIFETIME AGGREGATE 
                   LIMITS.

       ``The provisions of section 2708 shall apply to health 
     insurance coverage offered by a health insurance issuer in 
     the individual market in the same manner as they apply to 
     health insurance coverage offered by a health insurance 
     issuer in connection with a group health plan in the small or 
     large group market.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on or after 
     the date that is 1 year after the date of enactment of this 
     Act.
                                 ______
                                 
      By Mr. REID (for Mr. Rockefeller (for himself, Ms. Collins, Mr. 
        Kohl, Mr. Wyden, and Mr. Carper)):
  S. 1150. A bill to improve end-of-life care; to the Committee on 
Finance.
  Mr. ROCKEFELLER. Mr. President, I rise today with my friends and 
colleagues--Senators Collins, Kohl, Wyden and Carper--to introduce the 
Advance Planning and Compassionate Care Act of 2009, comprehensive 
legislation that recognizes the critical importance of advance care 
planning and quality end-of-life care. Senator Collins and I have 
worked on this legislation for over a decade--with the ultimate goal of 
one day passing comprehensive end-of-life care legislation. We are 
encouraged by the prospect of comprehensive health reform this year and 
believe that it is absolutely critical that end-of-life care provisions 
be included.
  In preparation for the impending health reform debate, Senator 
Collins and I decided last year that it was time to update our Advance 
Planning and Compassionate Care Act to incorporate all of the best 
ideas out there on improving end-of-life care--including new and 
innovative approaches being implemented in the states, approaches 
suggested by scholars in this field, and recommendations based on our 
own experiences with loved ones facing the end of life. This new and 
improved bill is truly a labor of love and we are certainly hopeful 
that we can finally get something comprehensive and meaningful done for 
the millions of individuals and families faced with the agonizing 
issues surrounding the end of life.
  A modern health care delivery system is well within our reach and 
something that we can start to achieve this year. A critical component 
of a modernized health system is the ability to address the health care 
needs of patients across the life-span--especially at the end of life. 
Death is a serious, personal, and complicated part of the life cycle. 
Yet, care at the end of life is eventually relevant to everyone. 
Americans deserve end-of-life care that is effective in providing 
information about diagnosis and prognosis, integrating appropriate 
support services, fulfilling individual wishes, and avoiding 
unnecessary disputes.
  The bitter dispute that played out publicly for Terri Schiavo and her 
family is an agonizing experience that countless other families quietly 
face over the care of a loved one because clear advance directives are 
not in place. End-of-life care is a very delicate, yet important, issue 
and we must act to ensure that all Americans have the dignity and 
comfort they deserve at the end of life. Services should be available 
to help patients and their families with the medical, psychological, 
spiritual, and practical issues surrounding death.
  Most people want to discuss advance directives when they are healthy 
and they want their families involved in the process. Yet, the vast 
majority of Americans have not completed an advance directive 
expressing their final wishes. In 2007, RAND conducted a comprehensive 
review of academic literature relating to end-of-life decision-making. 
This review found that only 18 to 30 percent of Americans have 
completed some type of advance directive expressing their end-of-life 
wishes. RAND also found that acutely ill individuals, for whom these 
decisions are particularly relevant, complete advance directives at 
only slightly higher rates--35 percent of dialysis patients and 32 
percent of Chronic Obstructive Pulmonary Disease, COPD, patients. 
Perhaps most alarmingly, between 65 and 76 percent of physicians whose 
patients had an advance directive were unaware of its existence.
  In its present form, end-of-life planning and care for most Americans 
is perplexing, disjointed, and lacking an active dialogue. In its 1997 
report entitled Approaching Death: Improving Care at the End of Life, 
the Institute of Medicine found several barriers to effective advance 
planning and end-of-life care that still persist today.
  In addition to the substantial burden of suffering experienced by 
many at the end of life, there are also significant financial 
consequences for family members and society as a whole that stem from 
ineffective end-of-life care. According to one Federal evaluation, 80 
percent of all deaths occur in hospitals--the most costly setting to 
deliver care--even though most people would prefer to die at home. 
Current studies indicate that around 25 percent of all Medicare 
spending occurs in the last year of life. Largely because of their 
poorer health status, dually eligible beneficiaries have Medicare costs 
that are about 1.5 times that of other Medicare beneficiaries. Research 
also shows significant variation in expenditures at the end-of-life by 
geography and hospital, without evidence that greater expenditures are 
associated with better outcomes or satisfaction.
  We must find ways to improve the quality of end-of-life care. Quality 
measures provide not only information for oversight, but data with 
which to improve care practices and models. No core sets of end-of-life 
quality measures are required across provider settings. Even for 
certified hospices, reporting of quality measures has only recently 
been required, with each hospice deciding its own indicators. Hospice 
surveys are behind schedule and not conducted frequently enough.
  Facilitating greater advance planning and improving care at the end 
of life also requires an adequate workforce. Unfortunately, there is a 
substantial shortage of health professionals who specialize in 
palliative care. There is a severe shortage of physicians and advance 
practice nurses trained in palliative medicine. Contributing to these 
shortages is a shortage of medical and nursing school faculty in 
palliative medicine and care. There is also a lack of content about 
end-of-life care in medical school curricula. Medical students in 
general receive very little formal end-of-life education. Almost half 
of medical residents in a survey felt unprepared to address patients' 
fears of dying. For Americans to have a full range of choices in end-
of-life care, we must strengthen our health care workforce, including 
palliative care education of physicians and other health professionals.
  Care at the end-of-life can, and should, be better and more 
consistent with what Americans want. The Advance Planning and 
Compassionate Care Act takes enormous steps forward to fully inform 
consumers of their treatment options at the end of life and to actually 
address patient end-of-life care needs when the time comes. To promote 
advance care planning, this legislation provides both patients and 
their physicians with the information and tools to help them in this 
most personal and often difficult discussion.
  Last year's Medicare Improvements for Patients and Providers Act, PL 
110-275, took a significant step forward toward improving advance care 
planning. MIPPA included a provision that I authored, requiring 
physicians to provide an advance care planning consultation as part of 
the Welcome to Medicare physical exam. Unfortunately, less than 10 
percent of new enrollees use the Welcome to Medicare visit. The MIPPA 
provision also does not address the advance care planning needs of 
existing Medicare enrollees.
  The legislation we are introducing today establishes physician 
payment under Medicare, Medicaid, and CHIP for vital patient advance 
care planning conversations. It provides help in documenting decisions 
from these conversations in the form of advance directives and in the 
form of actionable orders for life sustaining treatment. It also takes 
steps to address the problem of accessing advance directives when 
needed, including state grants for electronic registries.
  This legislation establishes a National Geriatric and Palliative Care 
Service Corps, modeled after the National Health Service Corps, to 
increase the woefully inadequate supply

[[Page S5863]]

of geriatric and palliative specialists and to even out their 
geographic distribution. It adopts MedPAC's 2009 hospice payment 
reforms aimed at aligning payment with the actual trajectory of 
resources expended over hospice episodes of care, while remaining 
within the constraints of current reimbursement. Demonstration projects 
are funded to explore ways to better meet the needs of patients over 
longer time periods than the 6-month prognoses inherent in the hospice 
benefit.
  Certification standards and processes are developed for hospital-
based palliative care teams. Such teams are critical to providing 
consultation and care to dying patients. Quality measurement and 
oversight are strengthened, with development of end-of-life measures 
across care settings and greater data reporting requirements of 
hospices--so that we can make sure the hospice benefit is keeping pace 
with the changing diagnostic mix of patients that hospice serves.
  Finally, this bill takes the important step of establishing a 
National Center on Palliative and End-of-Life Care within the NIH. This 
is a vital step toward prioritizing biomedical research in the areas of 
palliative and end-of-life care. It will also serve as a symbol to 
remind us that, as in other phases of life, we need care at the end of 
life that addresses our individual needs and circumstances.
  Death is a serious, personal, and complicated issue that is 
eventually relevant to each and every one of us. Americans deserve end-
of-life care that is effective in fulfilling individual wishes, 
avoiding unnecessary disputes, and, most importantly, providing quality 
end-of-life care. Therefore, I urge my colleagues to join us in 
improving end-of-life care and reducing the amount of grief that 
inevitably comes with losing those who we hold dear.
  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. 1150

       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 ``Advance 
     Planning and Compassionate Care Act of 2009''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

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

                     TITLE I--ADVANCE CARE PLANNING

              Subtitle A--Consumer and Provider Education

                       PART I--Consumer Education

                    subpart a--national initiatives

Sec. 101. Advance care planning telephone hotline.
Sec. 102. Advance care planning information clearinghouses.
Sec. 103. Advance care planning toolkit.
Sec. 104. National public education campaign.
Sec. 105. Update of Medicare and Social Security handbooks.
Sec. 106. Authorization of appropriations.

                 subpart b--state and local initiatives

Sec. 111. Financial assistance for advance care planning.
Sec. 112. Grants for programs for orders regarding life sustaining 
              treatment.

                      PART II--Provider Education

Sec. 121. Public provider advance care planning website.
Sec. 122. Continuing education for physicians and nurses.

   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

Sec. 131. Portability of advance directives.
Sec. 132. State advance directive registries; driver's license advance 
              directive notation.
Sec. 133. GAO study and report on establishment of national advance 
              directive registry.

      Subtitle C--National Uniform Policy on Advance Care Planning

Sec. 141. Study and report by the Secretary regarding the establishment 
              and implementation of a national uniform policy on 
              advance directives.

                      TITLE II--COMPASSIONATE CARE

                   Subtitle A--Workforce Development

                     PART I--Education and Training

Sec. 201. National Geriatric and Palliative Care Services Corps.
Sec. 202. Exemption of palliative medicine fellowship training from 
              Medicare graduate medical education caps.
Sec. 203. Medical school curricula.

        Subtitle B--Coverage Under Medicare, Medicaid, and CHIP

               PART I--Coverage of Advance Care Planning

Sec. 211. Medicare, Medicaid, and CHIP coverage.

                            PART II--Hospice

Sec. 221. Adoption of MedPAC hospice payment methodology 
              recommendations.
Sec. 222. Removing hospice inpatient days in setting per diem rates for 
              critical access hospitals.
Sec. 223. Hospice payments for dual eligible individuals residing in 
              long-term care facilities.
Sec. 224. Delineation of respective care responsibilities of hospice 
              programs and long-term care facilities.
Sec. 225. Adoption of MedPAC hospice program eligibility certification 
              and recertification recommendations.
Sec. 226. Concurrent care for children.
Sec. 227. Making hospice a required benefit under Medicaid and CHIP.
Sec. 228. Medicare Hospice payment model demonstration projects.
Sec. 229. MedPAC studies and reports.
Sec. 230. HHS Evaluations.

                    Subtitle C--Quality Improvement

Sec. 241. Patient satisfaction surveys.
Sec. 242. Development of core end-of-life care quality measures across 
              each relevant provider setting.
Sec. 243. Accreditation of hospital-based palliative care programs.
Sec. 244. Survey and data requirements for all Medicare participating 
              hospice programs.

       Subtitle D--Additional Reports, Research, and Evaluations

Sec. 251. National Center On Palliative and End-Of-Life Care.
Sec. 252. National Mortality Followback Survey.
Sec. 253. Demonstration projects for use of telemedicine services in 
              advance care planning.
Sec. 254. Inspector General investigation of raud and abuse.
Sec. 255. GAO study and report on provider adherence to advance 
              directives.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Advance care planning.--The term ``advance care 
     planning'' means the process of--
       (A) determining an individual's priorities, values and 
     goals for care in the future when the individual is no longer 
     able to express his or her wishes;
       (B) engaging family members, health care proxies, and 
     health care providers in an ongoing dialogue about--
       (i) the individual's wishes for care;
       (ii) what the future may hold for people with serious 
     illnesses or injuries;
       (iii) how individuals, their health care proxies, and 
     family members want their beliefs and preferences to guide 
     care decisions; and
       (iv) the steps that individuals and family members can take 
     regarding, and the resources available to help with, 
     finances, family matters, spiritual questions, and other 
     issues that impact seriously ill or dying patients and their 
     families; and
       (C) executing and updating advance directives and 
     appointing a health care proxy.
       (2) Advance directive.--The term ``advance directive'' 
     means a living will, medical directive, health care power of 
     attorney, durable power of attorney, or other written 
     statement by a competent individual that is recognized under 
     State law and indicates the individual's wishes regarding 
     medical treatment in the event of future incompetence. Such 
     term includes an advance health care directive and a health 
     care directive recognized under State law.
       (3) CHIP.--The term ``CHIP'' means the program established 
     under title XXI of the Social Security Act (42 U.S.C. 1397aa 
     et seq.).
       (4) End-of-life-care.--The term ``end-of-life care'' means 
     all aspects of care of a patient with a potentially fatal 
     condition, and includes care that is focused on specific 
     preparations for an impending death.
       (5) Health care power of attorney.--The term ``health care 
     power of attorney'' means a legal document that identifies a 
     health care proxy or decisionmaker for a patient who has the 
     authority to act on the patient's behalf when the patient is 
     unable to communicate his or her wishes for medical care on 
     matters that the patient specifies when he or she is 
     competent. Such term includes a durable power of attorney 
     that relates to medical care.
       (6) Living will.--The term ``living will'' means a legal 
     document--
       (A) used to specify the type of medical care (including any 
     type of medical treatment, including life-sustaining 
     procedures if that person becomes permanently unconscious or 
     is otherwise dying) that an individual wants provided or 
     withheld in the event the individual cannot speak for himself 
     or herself and cannot express his or her wishes; and
       (B) that requires a physician to honor the provisions of 
     upon receipt or to transfer the care of the individual 
     covered by the document to another physician that will honor 
     such provisions.
       (7) Medicaid.--The term ``Medicaid'' means the program 
     established under title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).
       (8) Medicare.--The term ``Medicare'' means the program 
     established under title

[[Page S5864]]

     XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
       (9) Orders for life-sustaining treatment.--The term 
     ``orders for life-sustaining treatment'' means a process for 
     focusing a patients' values, goals, and preferences on 
     current medical circumstances and to translate such into 
     visible and portable medical orders applicable across care 
     settings, including home, long-term care, emergency medical 
     services, and hospitals.
       (10) Palliative care.--The term ``palliative care'' means 
     interdisciplinary care for individuals with a life-
     threatening illness or injury relating to pain and symptom 
     management and psychological, social, and spiritual needs and 
     that seeks to improve the quality of life for the individual 
     and the individual's family.
       (11) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

                     TITLE I--ADVANCE CARE PLANNING

              Subtitle A--Consumer and Provider Education

                       PART I--CONSUMER EDUCATION

                    Subpart A--National Initiatives

     SEC. 101. ADVANCE CARE PLANNING TELEPHONE HOTLINE.

       (a) In General.--Not later than January 1, 2011, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall establish and operate 
     directly, or by grant, contract, or interagency agreement, a 
     24-hour toll-free telephone hotline to provide consumer 
     information regarding advance care planning, including--
       (1) an explanation of advanced care planning and its 
     importance;
       (2) issues to be considered when developing an individual's 
     advance care plan;
       (3) how to establish an advance directive;
       (4) procedures to help ensure that an individual's 
     directives for end-of-life care are followed;
       (5) Federal and State-specific resources for assistance 
     with advance care planning; and
       (6) hospice and palliative care (including their respective 
     purposes and services).
       (b) Establishment.--In carrying out the requirements under 
     subsection (a), the Director of the Centers for Disease 
     Control and Prevention may designate an existing 24-hour 
     toll-free telephone hotline or, if no such service is 
     available or appropriate, establish a new 24-hour toll-free 
     telephone hotline.

     SEC. 102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.

       (a) Expansion of National Clearinghouse for Long-Term Care 
     Information.--
       (1) Development.--Not later than January 1, 2010, the 
     Secretary shall develop an online clearinghouse to provide 
     comprehensive information regarding advance care planning.
       (2) Maintenance.--The advance care planning clearinghouse, 
     which shall be clearly identifiable and available on the 
     homepage of the Department of Health and Human Service's 
     National Clearinghouse for Long-Term Care Information 
     website, shall be maintained and publicized by the Secretary 
     on an ongoing basis.
       (3) Content.--The advance care planning clearinghouse shall 
     include--
       (A) any relevant content contained in the national public 
     education campaign required under section 104;
       (B) content addressing--
       (i) an explanation of advanced care planning and its 
     importance;
       (ii) issues to be considered when developing an 
     individual's advance care plan;
       (iii) how to establish an advance directive;
       (iv) procedures to help ensure that an individual's 
     directives for end-of-life care are followed; and
       (v) hospice and palliative care (including their respective 
     purposes and services); and
       (C) available Federal and State-specific resources for 
     assistance with advance care planning, including--
       (i) contact information for any State public health 
     departments that are responsible for issues regarding end-of-
     life care;
       (ii) contact information for relevant legal service 
     organizations, including those funded under the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (iii) advance directive forms for each State; and
       (D) any additional information, as determined by the 
     Secretary.
       (b) Establishment of Pediatric Advance Care Planning 
     Clearinghouse.--
       (1) Development.--Not later than January 1, 2011, the 
     Secretary, in consultation with the Assistant Secretary for 
     Children and Families of the Department of Health and Human 
     Services, shall develop an online clearinghouse to provide 
     comprehensive information regarding pediatric advance care 
     planning.
       (2) Maintenance.--The pediatric advance care planning 
     clearinghouse, which shall be clearly identifiable on the 
     homepage of the Administration for Children and Families 
     website, shall be maintained and publicized by the Secretary 
     on an ongoing basis.
       (3) Content.--The pediatric advance care planning 
     clearinghouse shall provide advance care planning information 
     specific to children with life-threatening illnesses or 
     injuries and their families.

     SEC. 103. ADVANCE CARE PLANNING TOOLKIT.

       (a) Development.--Not later than July 1, 2010, the 
     Secretary, in consultation with the Director of the Centers 
     for Disease Control and Prevention, shall develop an online 
     advance care planning toolkit.
       (b) Maintenance.--The advance care planning toolkit, which 
     shall be available in English, Spanish, and any other 
     languages that the Secretary deems appropriate, shall be 
     maintained and publicized by the Secretary on an ongoing 
     basis and made available on the following websites:
       (1) The Centers for Disease Control and Prevention.
       (2) The Department of Health and Human Service's National 
     Clearinghouse for Long-Term Care Information.
       (3) The Administration for Children and Families.
       (c) Content.--The advance care planning toolkit shall 
     include content addressing--
       (1) common issues and questions regarding advance care 
     planning, including individuals and resources to contact for 
     further inquiries;
       (2) advance directives and their uses, including living 
     wills and durable powers of attorney;
       (3) the roles and responsibilities of a health care proxy;
       (4) Federal and State-specific resources to assist 
     individuals and their families with advance care planning, 
     including--
       (A) the advance care planning toll-free telephone hotline 
     established under section 101;
       (B) the advance care planning clearinghouses established 
     under section 102;
       (C) the advance care planning toolkit established under 
     this section;
       (D) available State legal service organizations to assist 
     individuals with advance care planning, including those 
     organizations that receive funding pursuant to the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (E) website links or addresses for State-specific advance 
     directive forms; and
       (5) any additional information, as determined by the 
     Secretary.

     SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN.

       (a) National Public Education Campaign.--
       (1) In general.--Not later than January 1, 2011, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall, directly or through 
     grants, contracts, or interagency agreements, develop and 
     implement a national campaign to inform the public of the 
     importance of advance care planning and of an individual's 
     right to direct and participate in their health care 
     decisions.
       (2) Content of educational campaign.--The national public 
     education campaign established under paragraph (1) shall--
       (A) employ the use of various media, including regularly 
     televised public service announcements;
       (B) provide culturally and linguistically appropriate 
     information;
       (C) be conducted continuously over a period of not less 
     than 5 years;
       (D) identify and promote the advance care planning 
     information available on the Department of Health and Human 
     Service's National Clearinghouse for Long-Term Care 
     Information website and Administration for Children and 
     Families website, as well as any other relevant Federal or 
     State-specific advance care planning resources;
       (E) raise public awareness of the consequences that may 
     result if an individual is no longer able to express or 
     communicate their health care decisions;
       (F) address the importance of individuals speaking to 
     family members, health care proxies, and health care 
     providers as part of an ongoing dialogue regarding their 
     health care choices;
       (G) address the need for individuals to obtain readily 
     available legal documents that express their health care 
     decisions through advance directives (including living wills, 
     comfort care orders, and durable powers of attorney for 
     health care);
       (H) raise public awareness regarding the availability of 
     hospice and palliative care; and
       (I) encourage individuals to speak with their physicians 
     about their options and intentions for end-of-life care.
       (3) Evaluation.--
       (A) In general.--Not later than July 1, 2013, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall conduct a nationwide 
     survey to evaluate whether the national campaign conducted 
     under this subsection has achieved its goal of changing 
     public awareness, attitudes, and behaviors regarding advance 
     care planning.
       (B) Baseline survey.--In order to evaluate the 
     effectiveness of the national campaign, the Secretary shall 
     conduct a baseline survey prior to implementation of the 
     campaign.
       (C) Reporting requirement.--Not later than December 31, 
     2013, the Secretary shall report the findings of such survey, 
     as well as any recommendations that the Secretary determines 
     appropriate regarding the need for continuation or 
     legislative or administrative changes to facilitate changing 
     public awareness, attitudes, and behaviors regarding advance 
     care planning, to the appropriate committees of the Congress.
       (b) Repeal.--Section 4751(d) of the Omnibus Budget 
     Reconciliation Act of 1990 (42 U.S.C. 1396a note; Public Law 
     101-508) is repealed.

     SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.

       (a) Medicare & You Handbook.--
       (1) In general.--Not later than 60 days after the date of 
     enactment of this Act, the Secretary shall update the online 
     version of

[[Page S5865]]

     the ``Planning Ahead'' section of the Medicare & You Handbook 
     to include--
       (A) an explanation of advance care planning and advance 
     directives, including--
       (i) living wills;
       (ii) health care proxies; and
       (iii) after-death directives;
       (B) Federal and State-specific resources to assist 
     individuals and their families with advance care planning, 
     including--
       (i) the advance care planning toll-free telephone hotline 
     established under section 101;
       (ii) the advance care planning clearinghouses established 
     under section 102;
       (iii) the advance care planning toolkit established under 
     section 103;
       (iv) available State legal service organizations to assist 
     individuals with advance care planning, including those 
     organizations that receive funding pursuant to the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (v) website links or addresses for State-specific advance 
     directive forms; and
       (C) any additional information, as determined by the 
     Secretary.
       (2) Update of paper and subsequent versions.--The Secretary 
     shall include the information described in paragraph (1) in 
     all paper and electronic versions of the Medicare & You 
     Handbook that are published on or after the date that is 60 
     days after the date of enactment of this Act.
       (b) Social Security Handbook.--The Commissioner of Social 
     Security shall--
       (1) not later than 60 days after the date of enactment of 
     this Act, update the online version of the Social Security 
     Handbook for beneficiaries to include the information 
     described in subsection (a)(1); and
       (2) include such information in all paper and online 
     versions of such handbook that are published on or after the 
     date that is 60 days after the date of enactment of this Act.

     SEC. 106. AUTHORIZATION OF APPROPRIATIONS.

       There is authorized to be appropriated for the period of 
     fiscal years 2010 through 2014--
       (1) $195,000,000 to the Secretary to carry out sections 
     101, 102, 103, 104 and 105(a); and
       (2) $5,000,000 to the Commissioner of Social Security to 
     carry out section 105(b).

                 Subpart B--State and Local Initiatives

     SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.

       (a) Legal Assistance for Advance Care Planning.--
       (1) Definition of recipient.--Section 1002(6) of the Legal 
     Services Corporation Act (42 U.S.C. 2996a(6)) is amended by 
     striking ``clause (A) of'' and inserting ``subparagraph (A) 
     or (B) of''.
       (2) Advance care planning.--Section 1006 of the Legal 
     Services Corporation Act (42 U.S.C. 2996e) is amended--
       (A) in subsection (a)(1)--
       (i) by striking ``title, and (B) to make'' and inserting 
     the following: ``title;
       ``(C) to make''; and
       (ii) by inserting after subparagraph (A) the following:
       ``(B) to provide financial assistance, and make grants and 
     contracts, as described in subparagraph (A), on a competitive 
     basis for the purpose of providing legal assistance in the 
     form of advance care planning (as defined in section 3 of the 
     Advance Planning and Compassionate Care Act of 2009, and 
     including providing information about State-specific advance 
     directives, as defined in that section) for eligible clients 
     under this title, including providing such planning to the 
     family members of eligible clients and persons with power of 
     attorney to make health care decisions for the clients; 
     and''; and
       (B) in subsection (b), by adding at the end the following:
       ``(2) Advance care planning provided in accordance with 
     subsection (a)(1)(B) shall not be construed to violate the 
     Assisted Suicide Funding Restriction Act of 1997 (42 U.S.C. 
     14401 et seq.).''.
       (3) Reports.--Section 1008(a) of the Legal Services 
     Corporation Act (42 U.S.C. 2996g(a)) is amended by adding at 
     the end the following: ``The Corporation shall require such a 
     report, on an annual basis, from each grantee, contractor, or 
     other recipient of financial assistance under section 
     1006(a)(1)(B).''.
       (4) Authorization of appropriations.--Section 1010 of the 
     Legal Services Corporation Act (42 U.S.C. 2996i) is amended--
       (A) in subsection (a)--
       (i) by striking ``(a)'' and inserting ``(a)(1)'';
       (ii) in the last sentence, by striking ``Appropriations for 
     that purpose'' and inserting the following:
       ``(3) Appropriations for a purpose described in paragraph 
     (1) or (2)''; and
       (iii) by inserting before paragraph (3) (as designated by 
     clause (ii)) the following:
       ``(2) There are authorized to be appropriated to carry out 
     section 1006(a)(1)(B), $10,000,000 for each of fiscal years 
     2010, 2011, 2012, 2013, and 2014.''; and
       (B) in subsection (d), by striking ``subsection (a)'' and 
     inserting ``subsection (a)(1)''.
       (5) Effective date.--This subsection and the amendments 
     made by this subsection take effect July 1, 2010.
       (b) State Health Insurance Assistance Programs.--
       (1) In general.--The Secretary shall use amounts made 
     available under paragraph (3) to award grants to States for 
     State health insurance assistance programs receiving 
     assistance under section 4360 of the Omnibus Budget 
     Reconciliation Act of 1990 to provide advance care planning 
     services to Medicare beneficiaries, personal representatives 
     of such beneficiaries, and the families of such 
     beneficiaries. Such services shall include information 
     regarding State-specific advance directives and ways to 
     discuss individual care wishes with health care providers.
       (2) Requirements.--
       (A) Award of grants.--In making grants under this 
     subsection for a fiscal year, the Secretary shall satisfy the 
     following requirements:
       (i) Two-thirds of the total amount of funds available under 
     paragraph (3) for a fiscal year shall be allocated among 
     those States approved for a grant under this section that 
     have adopted the Uniform Health-Care Decisions Act drafted by 
     the National Conference of Commissioners on Uniform State 
     Laws and approved and recommended for enactment by all States 
     at the annual conference of such commissioners in 1993.
       (ii) One-third of the total amount of funds available under 
     paragraph (3) for a fiscal year shall be allocated among 
     those States approved for a grant under this section that 
     have adopted a uniform form for orders regarding life 
     sustaining treatment as defined in section 1861(hhh)(5) of 
     the Social Security Act (as amended by section 211 of this 
     Act) or a comparable approach to advance care planning.
       (B) Work plan; report.--As a condition of being awarded a 
     grant under this subsection, a State shall submit the 
     following to the Secretary:
       (i) An approved plan for expending grant funds.
       (ii) For each fiscal year for which the State is paid grant 
     funds under this subsection, an annual report regarding the 
     use of the funds, including the number of Medicare 
     beneficiaries served and their satisfaction with the services 
     provided.
       (C) Limitation.--No State shall be paid funds from a grant 
     made under this subsection prior to July 1, 2010.
       (3) Authorization of appropriations.--There is authorized 
     to be appropriated to the Secretary to the Centers for 
     Medicare & Medicaid Services Program Management Account, 
     $12,000,000 for each of fiscal years 2010 through 2014 for 
     purposes of awarding grants to States under paragraph (1).
       (c) Medicaid Transformation Grants for Advance Care 
     Planning.--Section 1903(z) of the Social Security Act (42 
     U.S.C. 1396b(z)) is amended--
       (1) in paragraph (2), by adding at the end the following 
     new subparagraph:
       ``(G) Methods for improving the effectiveness and 
     efficiency of medical assistance provided under this title by 
     making available to individuals enrolled in the State plan or 
     under a waiver of such plan information regarding advance 
     care planning (as defined in section 3 of the Advance 
     Planning and Compassionate Care Act of 2009), including at 
     time of enrollment or renewal of enrollment in the plan or 
     waiver, through providers, and through such other innovative 
     means as the State determines appropriate.'';
       (2) in paragraph (3), by adding at the end the following 
     new subparagraph:
       ``(D) Work plan required for award of advance care planning 
     grants.--Payment to a State under this subsection to adopt 
     the innovative methods described in paragraph (2)(G) is 
     conditioned on the State submitting to the Secretary an 
     approved plan for expending the funds awarded to the State 
     under this subsection.''; and
       (3) in paragraph (4)--
       (A) in subparagraph (A)--
       (i) in clause (i), by striking ``and'' at the end;
       (ii) in clause (ii), by striking the period at the end and 
     inserting ``; and''; and
       (iii) by inserting after clause (ii), the following new 
     clause:
       ``(iii) $20,000,000 for each of fiscal years 2010 through 
     2014.''; and
       (B) by striking subparagraph (B), and inserting the 
     following:
       ``(B) Allocation of funds.--The Secretary shall specify a 
     method for allocating the funds made available under this 
     subsection among States awarded a grant for fiscal year 2010, 
     2011, 2012, 2013, or 2014. Such method shall provide that--
       ``(i) 100 percent of such funds for each of fiscal years 
     2010 through 2014 shall be awarded to States that design 
     programs to adopt the innovative methods described in 
     paragraph (2)(G); and
       ``(ii) in no event shall a payment to a State awarded a 
     grant under this subsection for fiscal year 2010 be made 
     prior to July 1, 2010.''.
       (d) Advance Care Planning Community Training Grants.--
       (1) In general.--The Secretary shall use amounts made 
     available under paragraph (3) to award grants to area 
     agencies on aging (as defined in section 102 of the Older 
     Americans Act of 1965 (42 U.S.C. 3002)).
       (2) Requirements.--
       (A) Use of funds.--Funds awarded to an area agency on aging 
     under this subsection shall be used to provide advance care 
     planning education and training opportunities for local aging 
     service providers and organizations.
       (B) Work plan; report.--As a condition of being awarded a 
     grant under this subsection, an area agency on aging shall 
     submit the following to the Secretary:
       (i) An approved plan for expending grant funds.
       (ii) For each fiscal year for which the agency is paid 
     grant funds under this subsection, an annual report regarding 
     the use of the funds, including the number of Medicare 
     beneficiaries served and their satisfaction with the services 
     provided.

[[Page S5866]]

       (C) Limitation.--No area agency on aging shall be paid 
     funds from a grant made under this subsection prior to July 
     1, 2010.
       (3) Authorization of appropriations.--There is authorized 
     to be appropriated to the Secretary to the Centers for 
     Medicare & Medicaid Services Program Management Account, 
     $12,000,000 for each of fiscal years 2010 through 2014 for 
     purposes of awarding grants to area agencies on aging under 
     paragraph (1).
       (e) Nonduplication of Activities.--The Secretary shall 
     establish procedures to ensure that funds made available 
     under grants awarded under this section or pursuant to 
     amendments made by this section supplement, not supplant, 
     existing Federal funding, and that such funds are not used to 
     duplicate activities carried out under such grants or under 
     other Federally funded programs.

     SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE 
                   SUSTAINING TREATMENT.

       (a) In General.--The Secretary shall make grants to 
     eligible entities for the purpose of--
       (1) establishing new programs for orders regarding life 
     sustaining treatment in States or localities;
       (2) expanding or enhancing an existing program for orders 
     regarding life sustaining treatment in States or localities; 
     or
       (3) providing a clearinghouse of information on programs 
     for orders for life sustaining treatment and consultative 
     services for the development or enhancement of such programs.
       (b) Authorized Activities.--Activities funded through a 
     grant under this section for an area may include--
       (1) developing such a program for the area that includes 
     home care, hospice, long-term care, community and assisted 
     living residences, skilled nursing facilities, inpatient 
     rehabilitation facilities, hospitals, and emergency medical 
     services within the area;
       (2) securing consultative services and advice from 
     institutions with experience in developing and managing such 
     programs; and
       (3) expanding an existing program for orders regarding life 
     sustaining treatment to serve more patients or enhance the 
     quality of services, including educational services for 
     patients and patients' families or training of health care 
     professionals.
       (c) Distribution of Funds.--In funding grants under this 
     section, the Secretary shall ensure that, of the funds 
     appropriated to carry out this section for each fiscal year--
       (1) at least two-thirds are used for establishing or 
     developing new programs for orders regarding life sustaining 
     treatment; and
       (2) one-third is used for expanding or enhancing existing 
     programs for orders regarding life sustaining treatment.
       (d) Definitions.--In this section:
       (1) The term ``eligible entity'' includes--
       (A) an academic medical center, a medical school, a State 
     health department, a State medical association, a multi-State 
     taskforce, a hospital, or a health system capable of 
     administering a program for orders regarding life sustaining 
     treatment for a State or locality; or
       (B) any other health care agency or entity as the Secretary 
     determines appropriate.
       (2) The term ``order regarding life sustaining treatment'' 
     has the meaning given such term in section 1861(hhh)(5) of 
     the Social Security Act, as added by section 211.
       (3) The term ``program for orders regarding life sustaining 
     treatment'' means, with respect to an area, a program that 
     supports the active use of orders regarding life sustaining 
     treatment in the area.
       (e) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of the fiscal years 2009 through 
     2014.

                      PART II--PROVIDER EDUCATION

     SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.

       (a) Development.--Not later than January 1, 2010, the 
     Secretary, acting through the Administrator of the Centers 
     for Medicare & Medicaid Services and the Director of the 
     Agency for Healthcare Research and Quality, shall establish a 
     website for providers under Medicare, Medicaid, the 
     Children's Health Insurance Program, the Indian Health 
     Service (include contract providers) and other public health 
     providers on each individual's right to make decisions 
     concerning medical care, including the right to accept or 
     refuse medical or surgical treatment, and the existence of 
     advance directives.
       (b) Maintenance.--The website, shall be maintained and 
     publicized by the Secretary on an ongoing basis.
       (c) Content.--The website shall include content, tools, and 
     resources necessary to do the following:
       (1) Inform providers about the advance directive 
     requirements under the health care programs described in 
     subsection (a) and other State and Federal laws and 
     regulations related to advance care planning.
       (2) Educate providers about advance care planning quality 
     improvement activities.
       (3) Provide assistance to providers to--
       (A) integrate advance directives into electronic health 
     records, including oral directives; and
       (B) develop and disseminate advance care planning 
     informational materials for their patients.
       (4) Inform providers about advance care planning continuing 
     education requirements and opportunities.
       (5) Encourage providers to discuss advance care planning 
     with their patients of all ages.
       (6) Assist providers' understanding of the continuum of 
     end-of-life care services and supports available to patients, 
     including palliative care and hospice.
       (7) Inform providers of best practices for discussing end-
     of-life care with dying patients and their loved ones.

     SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.

       (a) In General.--Not later than January 1, 2012, the 
     Secretary, acting through the Director of Health Resources 
     and Services Administration, shall develop, in consultation 
     with health care providers and State boards of medicine and 
     nursing, a curriculum for continuing education that States 
     may adopt for physicians and nurses on advance care planning 
     and end-of-life care.
       (b) Content.--
       (1) In general.--The continuing education curriculum 
     developed under subsection (a) for physicians and nurses 
     shall, at a minimum, include--
       (A) a description of the meaning and importance of advance 
     care planning;
       (B) a description of advance directives, including living 
     wills and durable powers of attorney, and the use of such 
     directives;
       (C) palliative care principles and approaches to care; and
       (D) the continuum of end-of-life services and supports, 
     including palliative care and hospice.
       (2) Additional content for physicians.--The continuing 
     education curriculum for physicians developed under 
     subsection (a) shall include instruction on how to conduct 
     advance care planning with patients and their loved ones.

   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

     SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES.

       (a) Medicare.--Section 1866(f) of the Social Security Act 
     (42 U.S.C. 1395cc(f)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (B), by inserting ``and if presented by 
     the individual, to include the content of such advance 
     directive in a prominent part of such record'' before the 
     semicolon at the end;
       (B) in subparagraph (D), by striking ``and'' after the 
     semicolon at the end;
       (C) in subparagraph (E), by striking the period at the end 
     and inserting ``; and''; and
       (D) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) to provide each individual with the opportunity to 
     discuss issues relating to the information provided to that 
     individual pursuant to subparagraph (A) with an appropriately 
     trained professional.'';
       (2) in paragraph (3), by striking ``a written'' and 
     inserting ``an''; and
       (3) by adding at the end the following new paragraph:
       ``(5)(A) An advance directive validly executed outside of 
     the State in which such advance directive is presented by an 
     adult individual to a provider of services, a Medicare 
     Advantage organization, or a prepaid or eligible organization 
     shall be given the same effect by that provider or 
     organization as an advance directive validly executed under 
     the law of the State in which it is presented would be given 
     effect.
       ``(B)(i) The definition of an advanced directive shall also 
     include actual knowledge of instructions made while an 
     individual was able to express the wishes of such individual 
     with regard to health care.
       ``(ii) For purposes of clause (i), the term `actual 
     knowledge' means the possession of information of an 
     individual's wishes communicated to the health care provider 
     orally or in writing by the individual, the individual's 
     medical power of attorney representative, the individual's 
     health care surrogate, or other individuals resulting in the 
     health care provider's personal cognizance of these wishes. 
     Other forms of imputed knowledge are not actual knowledge.
       ``(C) The provisions of this paragraph shall preempt any 
     State law to the extent such law is inconsistent with such 
     provisions. The provisions of this paragraph shall not 
     preempt any State law that provides for greater portability, 
     more deference to a patient's wishes, or more latitude in 
     determining a patient's wishes.''.
       (b) Medicaid.--Section 1902(w) of the Social Security Act 
     (42 U.S.C. 1396a(w)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (B)--
       (i) by striking ``in the individual's medical record'' and 
     inserting ``in a prominent part of the individual's current 
     medical record''; and
       (ii) by inserting ``and if presented by the individual, to 
     include the content of such advance directive in a prominent 
     part of such record'' before the semicolon at the end;
       (B) in subparagraph (D), by striking ``and'' after the 
     semicolon at the end;
       (C) in subparagraph (E), by striking the period at the end 
     and inserting ``; and''; and
       (D) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) to provide each individual with the opportunity to 
     discuss issues relating to the information provided to that 
     individual pursuant to subparagraph (A) with an appropriately 
     trained professional.'';
       (2) in paragraph (4), by striking ``a written'' and 
     inserting ``an''; and

[[Page S5867]]

       (3) by adding at the end the following paragraph:
       ``(6)(A) An advance directive validly executed outside of 
     the State in which such advance directive is presented by an 
     adult individual to a provider or organization shall be given 
     the same effect by that provider or organization as an 
     advance directive validly executed under the law of the State 
     in which it is presented would be given effect.
       ``(B)(i) The definition of an advance directive shall also 
     include actual knowledge of instructions made while an 
     individual was able to express the wishes of such individual 
     with regard to health care.
       ``(ii) For purposes of clause (i), the term `actual 
     knowledge' means the possession of information of an 
     individual's wishes communicated to the health care provider 
     orally or in writing by the individual, the individual's 
     medical power of attorney representative, the individual's 
     health care surrogate, or other individuals resulting in the 
     health care provider's personal cognizance of these wishes. 
     Other forms of imputed knowledge are not actual knowledge.
       ``(C) The provisions of this paragraph shall preempt any 
     State law to the extent such law is inconsistent with such 
     provisions. The provisions of this paragraph shall not 
     preempt any State law that provides for greater portability, 
     more deference to a patient's wishes, or more latitude in 
     determining a patient's wishes.''.
       (c) CHIP.--Section 2107(e)(1) of the Social Security Act 
     (42 U.S.C. 1397gg(e)(1)) is amended--
       (1) by redesignating subparagraphs (E) through (L) as 
     subparagraphs (D) through (M), respectively; and
       (2) by inserting after subparagraph (D) the following:
       ``(E) Section 1902(w) (relating to advance directives).''.
       (d) Study and Report Regarding Implementation.--
       (1) Study.--The Secretary shall conduct a study regarding 
     the implementation of the amendments made by subsections (a) 
     and (b).
       (2) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the study conducted under paragraph (1), together 
     with recommendations for such legislation and administrative 
     actions as the Secretary considers appropriate.
       (e) Effective Dates.--
       (1) In general.--Subject to paragraph (2), the amendments 
     made by subsections (a), (b), and (c) shall apply to provider 
     agreements and contracts entered into, renewed, or extended 
     under title XVIII of the Social Security Act (42 U.S.C. 1395 
     et seq.), and to State plans under title XIX of such Act (42 
     U.S.C. 1396 et seq.) and State child health plans under title 
     XXI of such Act (42 U.S.C. 1397aa et seq.), on or after such 
     date as the Secretary specifies, but in no case may such date 
     be later than 1 year after the date of enactment of this Act.
       (2) Extension of effective date for state law amendment.--
     In the case of a State plan under title XIX of the Social 
     Security Act or a State child health plan under title XXI of 
     such Act which the Secretary determines requires State 
     legislation in order for the plan to meet the additional 
     requirements imposed by the amendments made by subsections 
     (b) and (c), the State plan shall not be regarded as failing 
     to comply with the requirements of such title solely on the 
     basis of its failure to meet these additional requirements 
     before the first day of the first calendar quarter beginning 
     after the close of the first regular session of the State 
     legislature that begins after the date of enactment of this 
     Act. For purposes of the previous sentence, in the case of a 
     State that has a 2-year legislative session, each year of the 
     session is considered to be a separate regular session of the 
     State legislature.

     SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S 
                   LICENSE ADVANCE DIRECTIVE NOTATION.

       Part P of title III of the Public Health Service Act (42 
     U.S.C. 280g) is amended--
       (1) by redesignating section 399R (as inserted by section 2 
     of Public Law 110-373) as section 399S;
       (2) by redesignating section 399R (as inserted by section 3 
     of Public Law 110-374) as section 399T; and
       (3) by adding at the end the following:

     ``SEC. 399U. STATE ADVANCE DIRECTIVE REGISTRIES.

       ``(a) State Advance Directive Registry.--In this section, 
     the term `State advance directive registry' means a secure, 
     electronic database that--
       ``(1) is available free of charge to residents of a State; 
     and
       ``(2) stores advance directive documents and makes such 
     documents accessible to medical service providers in 
     accordance with Federal and State privacy laws.
       ``(b) Grant Program.--Beginning on July 1, 2010, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall award grants on a 
     competitive basis to eligible entities to establish and 
     operate, directly or indirectly (by competitive grant or 
     competitive contract), State advance directive registries.
       ``(c) Eligible Entities.--
       ``(1) In general.--To be eligible to receive a grant under 
     this section, an entity shall--
       ``(A) be a State department of health; and
       ``(B) submit to the Director an application at such time, 
     in such manner, and containing--
       ``(i) a plan for the establishment and operation of a State 
     advance directive registry; and
       ``(ii) such other information as the Director may require.
       ``(2) No requirement of notation mechanism.--The Secretary 
     shall not require that an entity establish and operate a 
     driver's license advance directive notation mechanism for 
     State residents under section 399V to be eligible to receive 
     a grant under this section.
       ``(d) Annual Report.--For each year for which an entity 
     receives an award under this section, such entity shall 
     submit an annual report to the Director on the use of the 
     funds received pursuant to such award, including the number 
     of State residents served through the registry.
       ``(e) Authorization.--There is authorized to be 
     appropriated to carry out this section $20,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.

     ``SEC. 399V. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.

       ``(a) In General.--Beginning July 1, 2010, the Secretary, 
     acting through the Director of the Centers for Disease 
     Control and Prevention, shall award grants on a competitive 
     basis to States to establish and operate a mechanism for a 
     State resident with a driver's license to include a notice of 
     the existence of an advance directive for such resident on 
     such license.
       ``(b) Eligibility.--To be eligible to receive a grant under 
     this section, a State shall--
       ``(1) establish and operate a State advance directive 
     registry under section 399U; and
       ``(2) submit to the Director an application at such time, 
     in such manner, and containing--
       ``(A) a plan that includes a description of how the State 
     will--
       ``(i) disseminate information about advance directives at 
     the time of driver's license application or renewal;
       ``(ii) enable each State resident with a driver's license 
     to include a notice of the existence of an advance directive 
     for such resident on such license in a manner consistent with 
     the notice on such a license indicating a driver's intent to 
     be an organ donor; and
       ``(iii) coordinate with the State department of health to 
     ensure that, if a State resident has an advance directive 
     notice on his or her driver's license, the existence of such 
     advance directive is included in the State registry 
     established under section 399U; and
       ``(B) any other information as the Director may require.
       ``(c) Annual Report.--For each year for which a State 
     receives an award under this section, such State shall submit 
     an annual report to the Director on the use of the funds 
     received pursuant to such award, including the number of 
     State residents served through the mechanism.
       ``(d) Authorization.--There is authorized to be 
     appropriated to carry out this section $50,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.''.

     SEC. 133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL 
                   ADVANCE DIRECTIVE REGISTRY.

       (a) Study.--The Comptroller General of the United States 
     shall conduct a study on the feasibility of a national 
     registry for advance directives, taking into consideration 
     the constraints created by the privacy provisions enacted as 
     a result of the Health Insurance Portability and 
     Accountability Act of 1996 (Public Law 104-191).
       (b) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Comptroller General of the United 
     States shall submit to Congress a report on the study 
     conducted under subsection (a) together with recommendations 
     for such legislation and administrative action as the 
     Comptroller General of the United States determines to be 
     appropriate.

      Subtitle C--National Uniform Policy on Advance Care Planning

     SEC. 141. STUDY AND REPORT BY THE SECRETARY REGARDING THE 
                   ESTABLISHMENT AND IMPLEMENTATION OF A NATIONAL 
                   UNIFORM POLICY ON ADVANCE DIRECTIVES.

       (a) Study.--
       (1) In general.--The Secretary, acting through the Office 
     of the Assistant Secretary for Planning and Evaluation, shall 
     conduct a thorough study of all matters relating to the 
     establishment and implementation of a national uniform policy 
     on advance directives for individuals receiving items and 
     services under titles XVIII, XIX, or XXI of the Social 
     Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.; 1397aa et 
     seq.).
       (2) Matters studied.--The matters studied by the Secretary 
     under paragraph (1) shall include issues concerning--
       (A) family satisfaction that a patient's wishes, as stated 
     in the patient's advance directive, were carried out;
       (B) the portability of advance directives, including cases 
     involving the transfer of an individual from 1 health care 
     setting to another;
       (C) immunity from civil liability and criminal 
     responsibility for health care providers that follow the 
     instructions in an individual's advance directive that was 
     validly executed in, and consistent with the laws of, the 
     State in which it was executed;
       (D) conditions under which an advance directive is 
     operative;
       (E) revocation of an advance directive by an individual;
       (F) the criteria used by States for determining that an 
     individual has a terminal condition;
       (G) surrogate decisionmaking regarding end-of-life care;

[[Page S5868]]

       (H) the provision of adequate palliative care (as defined 
     in paragraph (3)), including pain management;
       (I) adequate and timely referrals to hospice care programs; 
     and
       (J) the end-of-life care needs of children and their 
     families.
       (3) Palliative care.--For purposes of paragraph (2)(H), the 
     term ``palliative care'' means interdisciplinary care for 
     individuals with a life-threatening illness or injury 
     relating to pain and symptom management and psychological, 
     social, and spiritual needs and that seeks to improve the 
     quality of life for the individual and the individual's 
     family.
       (b) Report to Congress.--Not later than 18 months after the 
     date of enactment of this Act, the Secretary shall submit to 
     Congress a report on the study conducted under subsection 
     (a), together with recommendations for such legislation and 
     administrative actions as the Secretary considers 
     appropriate.
       (c) Consultation.--In conducting the study and developing 
     the report under this section, the Secretary shall consult 
     with the Uniform Law Commissioners, and other interested 
     parties.

                      TITLE II--COMPASSIONATE CARE

                   Subtitle A--Workforce Development

                     PART I--EDUCATION AND TRAINING

     SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE SERVICES 
                   CORPS.

       Section 331 of the Public Health Service Act (42 U.S.C. 
     254d) is amended--
       (1) by redesignating subsection (j) as subsection (k); and
       (2) by inserting after subsection (i), the following:
       ``(j) National Geriatric and Palliative Care Services 
     Corps.--
       ``(1) Establishment.--Not later than January 1, 2012, the 
     Secretary shall establish within the National Health Service 
     Corps a National Geriatric and Palliative Care Services Corps 
     (referred to in this subsection as the `Corps') which shall 
     consist of--
       ``(A) such officers of the Regular and Reserve Corps of the 
     Service as the Secretary may designate;
       ``(B) such civilian employees of the United States as the 
     Secretary may appoint; and
       ``(C) such other individuals who are not employees of the 
     United States.
       ``(2) Duties.--The Corps shall be utilized by the Secretary 
     to provide geriatric and palliative care services within 
     health professional shortage areas.
       ``(3) Application of provisions.--The loan-forgiveness, 
     scholarship, and direct financial incentives programs 
     provided for under this section shall apply to physicians, 
     nurses, and other health professionals (as identified by the 
     Secretary) with respect to the training necessary to enable 
     such individuals to become geriatric or palliative care 
     specialists and provide geriatric and palliative care 
     services in health professional shortage areas.
       ``(4) Report.--Not later than 6 months prior to the date on 
     which the Secretary establishes the Corps under paragraph 
     (1), the Secretary shall submit to Congress a report 
     concerning the organization of the Corps, the application 
     process for membership in the Corps, and the funding 
     necessary for the Corps (targeted by profession and by 
     specialization).''.

     SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP 
                   TRAINING FROM MEDICARE GRADUATE MEDICAL 
                   EDUCATION CAPS.

       (a) Direct Graduate Medical Education.--Section 
     1886(h)(4)(F) of the Social Security Act (42 U.S.C. 
     1395ww(h)(4)(F)) is amended--
       (1) in clause (i), by inserting ``clause (iii) and'' after 
     ``subject to''; and
       (2) by adding at the end the following new clause:
       ``(iii) Increase allowed for palliative medicine fellowship 
     training.--For cost reporting periods beginning on or after 
     January 1, 2011, in applying clause (i), there shall not be 
     taken into account full-time equivalent residents in the 
     field of allopathic or osteopathic medicine who are in 
     palliative medicine fellowship training that is approved by 
     the Accreditation Council for Graduate Medical Education.''.
       (b) 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.''.

     SEC. 203. MEDICAL SCHOOL CURRICULA.

       (a) In General.--The Secretary, in consultation with the 
     Association of American Medical Colleges, shall establish 
     guidelines for the imposition by medical schools of a minimum 
     amount of end-of-life training as a requirement for obtaining 
     a Doctor of Medicine degree in the field of allopathic or 
     osteopathic medicine.
       (b) Training.--Under the guidelines established under 
     subsection (a), minimum training shall include--
       (1) training in how to discuss and help patients and their 
     loved ones with advance care planning;
       (2) with respect to students and trainees who will work 
     with children, specialized pediatric training;
       (3) training in the continuum of end-of-life services and 
     supports, including palliative care and hospice;
       (4) training in how to discuss end-of-life care with dying 
     patients and their loved ones; and
       (5) medical and legal issues training.
       (c) Distribution.--Not later than January 1, 2011, the 
     Secretary shall disseminate the guidelines established under 
     subsection (a) to medical schools.
       (d) Compliance.--Effective beginning not later than July 1, 
     2012, a medical school that is receiving Federal assistance 
     shall be required to implement the guidelines established 
     under subsection (a). A medical school that the Secretary 
     determines is not implementing such guidelines shall not be 
     eligible for Federal assistance.

        Subtitle B--Coverage Under Medicare, Medicaid, and CHIP

               PART I--COVERAGE OF ADVANCE CARE PLANNING

     SEC. 211. MEDICARE, MEDICAID, AND CHIP COVERAGE.

       (a) Medicare.--
       (1) In general.--Section 1861 of the Social Security Act 
     (42 U.S.C. 1395x) is amended--
       (A) in subsection (s)(2)--
       (i) by striking ``and'' at the end of subparagraph (DD);
       (ii) by adding ``and'' at the end of subparagraph (EE); and
       (iii) by adding at the end the following new subparagraph:
       ``(FF) advance care planning consultation (as defined in 
     subsection (hhh)(1));''; and
       (B) by adding at the end the following new subsection:

                  ``Advance Care Planning Consultation

       ``(hhh)(1) Subject to paragraphs (3) and (4), the term 
     `advance care planning consultation' means a consultation 
     between the individual and a practitioner described in 
     paragraph (2) regarding advance care planning, if, subject to 
     subparagraphs (A) and (B) of paragraph (3), the individual 
     involved has not had such a consultation within the last 5 
     years. Such consultation shall include the following:
       ``(A) An explanation by the practitioner of advance care 
     planning, including key questions and considerations, 
     important steps, and suggested people to talk to.
       ``(B) An explanation by the practitioner of advance 
     directives, including living wills and durable powers of 
     attorney, and their uses.
       ``(C) An explanation by the practitioner of the role and 
     responsibilities of a health care proxy.
       ``(D) The provision by the practitioner of a list of 
     national and State-specific resources to assist consumers and 
     their families with advance care planning, including the 
     national toll-free hotline, the advance care planning 
     clearinghouses, and State legal service organizations 
     (including those funded through the Older Americans Act).
       ``(E) An explanation by the practitioner of the continuum 
     of end-of-life services and supports available, including 
     palliative care and hospice, and benefits for such services 
     and supports that are available under this title.
       ``(F)(i) Subject to clause (ii), an explanation of orders 
     regarding life sustaining treatment or similar orders, which 
     shall include--
       ``(I) the reasons why the development of such an order is 
     beneficial to the individual and the individual's family and 
     the reasons why such an order should be updated periodically 
     as the health of the individual changes;
       ``(II) the information needed for an individual or legal 
     surrogate to make informed decisions regarding the completion 
     of such an order; and
       ``(III) the identification of resources that an individual 
     may use to determine the requirements of the State in which 
     such individual resides so that the treatment wishes of that 
     individual will be carried out if the individual is unable to 
     communicate those wishes, including requirements regarding 
     the designation of a surrogate decisionmaker (also known as a 
     health care proxy).
       ``(ii) The Secretary may limit the requirement for 
     explanations under clause (i) to consultations furnished in 
     States, localities, or other geographic areas in which orders 
     described in such clause have been widely adopted.
       ``(2) A practitioner described in this paragraph is--
       ``(A) a physician (as defined in subsection (r)(1)); and
       ``(B) a nurse practitioner or physician's assistant who has 
     the authority under State law to sign orders for life 
     sustaining treatments.
       ``(3)(A) An initial preventive physical examination under 
     subsection (ww), including any related discussion during such 
     examination, shall not be considered an advance care planning 
     consultation for purposes of applying the 5-year limitation 
     under paragraph (1).
       ``(B) An advance care planning consultation with respect to 
     an individual shall be conducted more frequently than 
     provided under paragraph (1) if there is a significant change 
     in the health condition of the individual, including 
     diagnosis of a chronic, progressive, life-limiting disease, a 
     life-threatening or terminal diagnosis or life-threatening 
     injury, or upon admission to a skilled nursing facility, a 
     long-term care facility (as defined by the Secretary), or a 
     hospice program.
       ``(4) A consultation under this subsection may include the 
     formulation of an order regarding life sustaining treatment 
     or a similar order.
       ``(5)(A) For purposes of this section, the term `order 
     regarding life sustaining treatment' means, with respect to 
     an individual,

[[Page S5869]]

     an actionable medical order relating to the treatment of that 
     individual that--
       ``(i) is signed and dated by a physician (as defined in 
     subsection (r)(1)) or another health care professional (as 
     specified by the Secretary and who is acting within the scope 
     of the professional's authority under State law in signing 
     such an order) and is in a form that permits it to stay with 
     the patient and be followed by health care professionals and 
     providers across the continuum of care, including home care, 
     hospice, long-term care, community and assisted living 
     residences, skilled nursing facilities, inpatient 
     rehabilitation facilities, hospitals, and emergency medical 
     services;
       ``(ii) effectively communicates the individual's 
     preferences regarding life sustaining treatment, including an 
     indication of the treatment and care desired by the 
     individual;
       ``(iii) is uniquely identifiable and standardized within a 
     given locality, region, or State (as identified by the 
     Secretary);
       ``(iv) is portable across care settings; and
       ``(v) may incorporate any advance directive (as defined in 
     section 1866(f)(3)) if executed by the individual.
       ``(B) The level of treatment indicated under subparagraph 
     (A)(ii) may range from an indication for full treatment to an 
     indication to limit some or all or specified interventions. 
     Such indicated levels of treatment may include indications 
     respecting, among other items--
       ``(i) the intensity of medical intervention if the patient 
     is pulseless, apneic, or has serious cardiac or pulmonary 
     problems;
       ``(ii) the individual's desire regarding transfer to a 
     hospital or remaining at the current care setting;
       ``(iii) the use of antibiotics; and
       ``(iv) the use of artificially administered nutrition and 
     hydration.''.
       (2) Payment.--Section 1848(j)(3) of the Social Security Act 
     (42 U.S.C. 1395w-4(j)(3)) is amended by inserting 
     ``(2)(FF),'' after ``(2)(EE),''.
       (3) Frequency limitation.--Section 1862(a) of the Social 
     Security Act (42 U.S.C. 1395y(a)(1)) is amended--
       (A) in paragraph (1)--
       (i) in subparagraph (N), by striking ``and'' at the end;
       (ii) in subparagraph (O) by striking the semicolon at the 
     end and inserting ``, and''; and
       (iii) by adding at the end the following new subparagraph:
       ``(P) in the case of advance care planning consultations 
     (as defined in section 1861(hhh)(1)), which are performed 
     more frequently than is covered under such section;''; and
       (B) in paragraph (7), by striking ``or (K)'' and inserting 
     ``(K), or (P)''.
       (4) Effective date.--The amendments made by this subsection 
     shall apply to consultations furnished on or after January 1, 
     2011.
       (b) Medicaid.--
       (1) Mandatory benefit.--Section 1902(a)(10)(A) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended in 
     the matter preceding clause (i) by striking ``and (21)'' and 
     inserting ``, (21), and (28)''.
       (2) Medical assistance.--Section 1905 of such Act (42 
     U.S.C. 1396d) is amended--
       (A) in subsection (a)--
       (i) in paragraph (27), by striking ``and'' at the end;
       (ii) by redesignating paragraph (28) as paragraph (29); and
       (iii) by inserting after paragraph (27) the following new 
     paragraph:
       ``(28) advance care planning consultations (as defined in 
     subsection (y));''; and
       (B) by adding at the end the following:
       ``(y)(1) For purposes of subsection (a)(28), the term 
     `advance care planning consultation' means a consultation 
     between the individual and a practitioner described in 
     paragraph (2) regarding advance care planning, if, subject to 
     paragraph (3), the individual involved has not had such a 
     consultation within the last 5 years. Such consultation shall 
     include the following:
       ``(A) An explanation by the practitioner of advance care 
     planning, including key questions and considerations, 
     important steps, and suggested people to talk to.
       ``(B) An explanation by the practitioner of advance 
     directives, including living wills and durable powers of 
     attorney, and their uses.
       ``(C) An explanation by the practitioner of the role and 
     responsibilities of a health care proxy.
       ``(D) The provision by the practitioner of a list of 
     national and State-specific resources to assist consumers and 
     their families with advance care planning, including the 
     national toll-free hotline, the advance care planning 
     clearinghouses, and State legal service organizations 
     (including those funded through the Older Americans Act).
       ``(E) An explanation by the practitioner of the continuum 
     of end-of-life services and supports available, including 
     palliative care and hospice, and benefits for such services 
     and supports that are available under this title.
       ``(F)(i) Subject to clause (ii), an explanation of orders 
     for life sustaining treatments or similar orders, which shall 
     include--
       ``(I) the reasons why the development of such an order is 
     beneficial to the individual and the individual's family and 
     the reasons why such an order should be updated periodically 
     as the health of the individual changes;
       ``(II) the information needed for an individual or legal 
     surrogate to make informed decisions regarding the completion 
     of such an order; and
       ``(III) the identification of resources that an individual 
     may use to determine the requirements of the State in which 
     such individual resides so that the treatment wishes of that 
     individual will be carried out if the individual is unable to 
     communicate those wishes, including requirements regarding 
     the designation of a surrogate decisionmaker (also known as a 
     health care proxy).
       ``(ii) The Secretary may limit the requirement for 
     explanations under clause (i) to consultations furnished in 
     States, localities, or other geographic areas in which orders 
     described in such clause have been widely adopted.
       ``(2) A practitioner described in this paragraph is--
       ``(A) a physician (as defined in section 1861(r)(1)); and
       ``(B) a nurse practitioner or physician's assistant who has 
     the authority under State law to sign orders for life 
     sustaining treatments.
       ``(3) An advance care planning consultation with respect to 
     an individual shall be conducted more frequently than 
     provided under paragraph (1) if there is a significant change 
     in the health condition of the individual including diagnosis 
     of a chronic, progressive, life-limiting disease, a life-
     threatening or terminal diagnosis or life-threatening injury, 
     or upon admission to a nursing facility, a long-term care 
     facility (as defined by the Secretary), or a hospice program.
       ``(4) A consultation under this subsection may include the 
     formulation of an order regarding life sustaining treatment 
     or a similar order.
       ``(5) For purposes of this subsection, the term `orders 
     regarding life sustaining treatment' has the meaning given 
     that term in section 1861(hhh)(5).''.
       (c) CHIP.--
       (1) Child health assistance.--Section 2110(a) of the Social 
     Security Act (42 U.S.C. 1397jj) is amended--
       (A) by redesignating paragraph (28) as paragraph (29); and
       (B) by inserting after paragraph (27), the following:
       ``(28) Advance care planning consultations (as defined in 
     section 1905(y)).''.
       (2) Mandatory coverage.--
       (A) In general.--Section 2103 of such Act (42 U.S.C. 
     1397cc), is amended--
       (i) in subsection (a), in the matter preceding paragraph 
     (1), by striking ``and (7)'' and inserting ``(7), and (9)''; 
     and
       (ii) in subsection (c), by adding at the end the following:
       ``(9) End-of-life care.--The child health assistance 
     provided to a targeted low-income child shall include 
     coverage of advance care planning consultations (as defined 
     in section 1905(y) and at the same payment rate as the rate 
     that would apply to such a consultation under the State plan 
     under title XIX).''.
       (B) Conforming amendment.--Section 2102(a)(7)(B) of such 
     Act (42 U.S.C. 1397bb(a)(7)(B)) is amended by striking 
     ``section 2103(c)(5)'' and inserting ``paragraphs (5) and (9) 
     of section 2103(c)''.
       (d) Definition of Advance Directive Under Medicare, 
     Medicaid, and CHIP.--
       (1) Medicare.--Section 1866(f)(3) of the Social Security 
     Act (42 U.S.C. 1395cc(f)(3)) is amended by striking ``means'' 
     and all that follows through the period and inserting ``means 
     a living will, medical directive, health care power of 
     attorney, durable power of attorney, or other written 
     statement by a competent individual that is recognized under 
     State law and indicates the individual's wishes regarding 
     medical treatment in the event of future incompetence. Such 
     term includes an advance health care directive and a health 
     care directive recognized under State law.''.
       (2) Medicaid and chip.--Section 1902(w)(4) of such Act (42 
     U.S.C. 1396a(w)(4)) is amended by striking ``means'' and all 
     that follows through the period and inserting ``means a 
     living will, medical directive, health care power of 
     attorney, durable power of attorney, or other written 
     statement by a competent individual that is recognized under 
     State law and indicates the individual's wishes regarding 
     medical treatment in the event of future incompetence. Such 
     term includes an advance health care directive and a health 
     care directive recognized under State law.''.
       (e) Effective Date.--The amendments made by this section 
     take effect January 1, 2010.

                            PART II--HOSPICE

     SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METHODOLOGY 
                   RECOMMENDATIONS.

       Section 1814(i) of the Social Security Act (42 U.S.C. 
     1395f(i)) is amended by adding at the end the following new 
     paragraph:
       ``(6)(A) The Secretary shall conduct an evaluation of the 
     recommendations of the Medicare Payment Commission for 
     reforming the hospice care benefit under this title that are 
     contained in chapter 6 of the Commission's report entitled 
     `Report to Congress: Medicare Payment Policy (March 2009)', 
     including the impact that such recommendations if implemented 
     would have on access to care and the quality of care. In 
     conducting such evaluation, the Secretary shall take into 
     account data collected in accordance with section 263(b) of 
     the Advance Planning and Compassionate Care Act of 2009.
       ``(B) Based on the results of the examination conducted 
     under subparagraph (A), the

[[Page S5870]]

     Secretary shall make appropriate refinements to the 
     recommendations described in subparagraph (A). Such 
     refinements shall take into account--
       ``(i) the impact on patient populations with longer that 
     average lengths of stay;
       ``(ii) the impact on populations with shorter that average 
     lengths of stay; and
       ``(iii) the utilization patterns of hospice providers in 
     underserved areas, including rural hospices.
       ``(C) Not later than January 1, 2013, the Secretary shall 
     submit to Congress a report that contains a detailed 
     description of--
       ``(i) the refinements determined appropriate by the 
     Secretary under subparagraph (B);
       ``(ii) the revisions that the Secretary will implement 
     through regulation under this title pursuant to subparagraph 
     (D); and
       ``(iii) the revisions that the Secretary determines require 
     additional legislative action by Congress.
       ``(D)(i) The Secretary shall implement the recommendations 
     described in subparagraph (A), as refined under subparagraph 
     (B).
       ``(ii) Subject to clause (iii), the implementation of such 
     recommendations shall apply to hospice care furnished on or 
     after January 1, 2014.
       ``(iii) The Secretary shall establish an appropriate 
     transition to the implementation of such recommendations.
       ``(E) For purposes of carrying out the provisions of this 
     paragraph, the Secretary shall provide for the transfer, from 
     the Federal Hospital Insurance Trust Fund under section 1817, 
     of such sums as may be necessary to the Centers for Medicare 
     & Medicaid Services Program Management Account.''.

     SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SETTING PER DIEM 
                   RATES FOR CRITICAL ACCESS HOSPITALS.

       Section 1814(l) of the Social Security Act (42 U.S.C. 
     1395f(l)), as amended by section 4102(b)(2) of the HITECH Act 
     (Public Law 111-5), is amended by adding at the end the 
     following new paragraph:
       ``(6) For cost reporting periods beginning on or after 
     January 1, 2011, the Secretary shall remove Medicare-
     certified hospice inpatient days from the calculation of per 
     diem rates for inpatient critical access hospital 
     services.''.

     SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS 
                   RESIDING IN LONG-TERM CARE FACILITIES.

       (a) In General.--Section 1888 of the Social Security Act 
     (42 U.S.C. 1395yy) is amended by adding at the end the 
     following new subsection:
       ``(f) Payments for Dual Eligible Individuals Residing in 
     Long-Term Care Facilities.--For cost reporting periods 
     beginning on or after January 1, 2011, the Secretary, acting 
     through the Administrator of the Centers for Medicare & 
     Medicaid Services, shall establish procedures under which 
     payments for room and board under the State Medicaid plan 
     with respect to an applicable individual are made directly to 
     the long-term care facility (as defined by the Secretary for 
     purposes of title XIX) the individual is a resident of. For 
     purposes of the preceding sentence, the term `applicable 
     individual' means an individual who is entitled to or 
     enrolled for benefits under part A or enrolled for benefits 
     under part B and is eligible for medical assistance for 
     hospice care under a State plan under title XIX.''.
       (b) State Plan Requirement.--
       (1) In general.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 1396a(a)) is amended--
       (A) in paragraph (72), by striking ``and'' at the end;
       (B) in paragraph (73), by striking the period at the end 
     and inserting ``; and''; and
       (C) by inserting after paragraph (73) the following new 
     paragraph:
       ``(74) provide that the State will make payments for room 
     and board with respect to applicable individuals in 
     accordance with section 1888(f).''.
       (2) Effective date.--
       (A) In general.--Except as provided in subparagraph (B), 
     the amendments made by paragraph (1) take effect on January 
     1, 2011.
       (B) Extension of effective date for state law amendment.--
     In the case of a State plan under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.) which the Secretary 
     determines requires State legislation in order for the plan 
     to meet the additional requirements imposed by the amendments 
     made by paragraph (1), the State plan shall not be regarded 
     as failing to comply with the requirements of such title 
     solely on the basis of its failure to meet these additional 
     requirements before the first day of the first calendar 
     quarter beginning after the close of the first regular 
     session of the State legislature that begins after the date 
     of enactment of this Act. For purposes of the previous 
     sentence, in the case of a State that has a 2-year 
     legislative session, each year of the session is considered 
     to be a separate regular session of the State legislature.

     SEC. 224. DELINEATION OF RESPECTIVE CARE RESPONSIBILITIES OF 
                   HOSPICE PROGRAMS AND LONG-TERM CARE FACILITIES.

       Section 1888 of the Social Security Act (42 U.S.C. 1395yy), 
     as amended by section 223(a), is amended by adding at the end 
     the following new subsection:
       ``(g) Delineation of Respective Care Responsibilities of 
     Hospice Programs and Long-Term Care Facilities.--Not later 
     than July 1, 2011, the Secretary, acting through the 
     Administrator of the Centers for Medicare & Medicaid 
     Services, shall delineate and enforce the respective care 
     responsibilities of hospice programs and long-term care 
     facilities (as defined by the Secretary for purposes of title 
     XIX) with respect to individuals residing in such facilities 
     who are furnished hospice care.''.

     SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY 
                   CERTIFICATION AND RECERTIFICATION 
                   RECOMMENDATIONS.

       In accordance with the recommendations of the Medicare 
     Payment Advisory Commission contained in the March 2009 
     report entitled ``Report to Congress: Medicare Payment 
     Policy'', section 1814(a)(7) of the Social Security Act (42 
     U.S.C. 1395f(a)(7)) is amended--
       (1) in subparagraph (B), by striking ``and'' at the end; 
     and
       (2) by adding at the end the following new subparagraph:
       ``(D) on or after January 1, 2011--
       ``(i) a hospice physician or advance practice nurse visits 
     the individual to determine continued eligibility of the 
     individual for hospice care prior to the 180th-day 
     recertification and each subsequent recertification under 
     subparagraph (A)(ii) and attests that such visit took place 
     (in accordance with procedures established by the Secretary, 
     in consultation with the Administrator of the Centers for 
     Medicare & Medicaid Services); and
       ``(ii) any certification or recertification under 
     subparagraph (A) includes a brief narrative describing the 
     clinical basis for the individual's prognosis (in accordance 
     with procedures established by the Secretary, in consultation 
     with the Administrator of the Centers for Medicare & Medicaid 
     Services); and''.

     SEC. 226. CONCURRENT CARE FOR CHILDREN.

       (a) Permitting Medicare Hospice Beneficiaries 18 Years of 
     Age or Younger to Receive Curative Care.--
       (1) In general.--Section 1812 of the Social Security Act 
     (42 U.S.C. 1395d) is amended--
       (A) in subsection (a)(4), by inserting ``(subject to the 
     second sentence of subsection (d)(2)(A))'' after ``in lieu of 
     certain other benefits''; and
       (B) in subsection (d)--
       (i) in paragraph (1), by inserting `` , subject to the 
     second sentence of paragraph (2)(A),'' after ``instead''; and
       (ii) in paragraph (2)(A), by adding at the end the 
     following new sentence: ``Clause (ii)(I) shall not apply to 
     an individual who is 18 years of age or younger.''
       (2) Conforming amendment.--Section 1862(a)(1)(C) of the 
     Social Security Act (42 U.S.C. 1395y(a)(1)(C)) is amended 
     inserting ``subject to the second sentence of section 
     1812(d)(2)(A),'' after ``hospice care,''.
       (b) Application to Medicaid and CHIP.--
       (1) Medicaid.--Section 1905(o)(1)(A) of the Social Security 
     Act (42 U.S.C. 1395d(o)(1)(A)) is amended by inserting 
     ``(subject, in the case of an individual who is a child, to 
     the second sentence of such section)'' after ``section 
     1812(d)(2)(A)''.
       (2) CHIP.--Section 2110(a)(23) of the Social Security Act 
     (42 U.S.C. 1397jj(a)(23)) is amended by inserting 
     ``(concurrent, in the case of an individual who is a child, 
     with care related to the treatment of the individual's 
     condition with respect to which a diagnosis of terminal 
     illness has been made)'' after ``hospice care''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.

     SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER MEDICAID 
                   AND CHIP.

       (a) Mandatory Benefit.--
       (1) Medicaid.--
       (A) In general.--Section 1902(a)(10)(A) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)), as amended by 
     section 211(b)(1), is amended in the matter preceding clause 
     (i) by inserting ``(18),'' after ``(17),''.
       (B) Conforming amendment.--Section 1902(a)(10)(C) of such 
     Act (42 U.S.C. 1396a(a)(10)(C)) is amended--
       (i) in clause (iii)--

       (I) in subclause (I), by inserting ``and hospice care'' 
     after ``ambulatory services''; and
       (II) in subclause (II), by inserting ``and hospice care'' 
     after ``delivery services''; and

       (ii) in clause (iv), by inserting ``and (18)'' after 
     ``(17)''.
       (2) CHIP.--Section 2103(c)(9) of such Act (42 U.S.C. 
     1397cc(c)(9))), as added by section 211(c)(2)(A), is amended 
     by inserting ``and hospice care'' before the period.
       (b) Effective Date.--The amendments made subsection (a) 
     take effect on January 1, 2011.

     SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEMONSTRATION 
                   PROJECTS.

       (a) Establishment.--Not later than July 1, 2012, the 
     Secretary, acting through the Administrator of the Centers 
     for Medicare & Medicaid Services and the Director of the 
     Agency for Healthcare Research and Quality, shall conduct 
     demonstration projects to examine ways to improve how the 
     Medicare hospice care benefit predicts disease trajectory. 
     Projects shall include the following models:
       (1) Models that better and more appropriately care for, and 
     transition as needed, patients in their last years of life 
     who need palliative care, but do not qualify for hospice care 
     under the Medicare hospice eligibility criteria.
       (2) Models that better and more appropriately care for 
     long-term patients who are not recertified in hospice but 
     still need palliative care.
       (3) Any other models determined appropriate by the 
     Secretary.

[[Page S5871]]

       (b) Waiver Authority.--The Secretary may waive compliance 
     of such requirements of titles XI and XVIII of the Social 
     Security Act as the Secretary determines necessary to conduct 
     the demonstration projects under this section.
       (c) Reports.--The Secretary shall submit to Congress 
     periodic reports on the demonstration projects conducted 
     under this section.

     SEC. 229. MEDPAC STUDIES AND REPORTS.

       (a) Study and Report Regarding an Alternative Payment 
     Methodology for Hospice Care Under the Medicare Program.--
       (1) Study.--The Medicare Payment Advisory Commission (in 
     this section referred to as the ``Commission'') shall conduct 
     a study on the establishment of a reimbursement system for 
     hospice care furnished under the Medicare program that is 
     based on diagnoses. In conducting such study, the Commission 
     shall use data collected under new provider data 
     requirements. Such study shall include an analysis of the 
     following:
       (A) Whether such a reimbursement system better meets 
     patient needs and better corresponds with provider resource 
     expenditures than the current system.
       (B) Whether such a reimbursement system improves quality, 
     including facilitating standardization of care toward best 
     practices and diagnoses-specific clinical pathways in 
     hospice.
       (C) Whether such a reimbursement system could address 
     concerns about the blanket 6-month terminal prognosis 
     requirement in hospice.
       (D) Whether such a reimbursement system is more cost 
     effective than the current system.
       (E) Any other areas determined appropriate by the 
     Commission.
       (2) Report.--Not later than June 15, 2013, the Commission 
     shall submit to Congress a report on the study conducted 
     under subsection (a) together with recommendations for such 
     legislation and administrative action as the Commission 
     determines appropriate.
       (b) Study and Report Regarding Rural Hospice Transportation 
     Costs Under the Medicare Program.--
       (1) Study.--The Commission shall conduct a study on rural 
     Medicare hospice transportation mileage to determine 
     potential Medicare reimbursement changes to account for 
     potential higher costs.
       (2) Report.--Not later than June 15, 2013, the Commission 
     shall submit to Congress a report on the study conducted 
     under subsection (a) together with recommendations for such 
     legislation and administrative action as the Commission 
     determines appropriate.
       (c) Evaluation of Reimbursement Disincentives To Elect 
     Medicare Hospice Within the Medicare Skilled Nursing Facility 
     Benefit.--
       (1) Study.--The Commission shall conduct a study to 
     determine potential Medicare reimbursement changes to remove 
     Medicare reimbursement disincentives for patients in a 
     skilled nursing facility who want to elect hospice.
       (2) Report.--Not later than June 15, 2013, the Commission 
     shall submit to Congress a report on the study conducted 
     under subsection (a) together with recommendations for such 
     legislation and administrative action as the Commission 
     determines appropriate.

     SEC. 230. HHS EVALUATIONS.

       (a) Evaluation of Access to Hospice and Hospital-Based 
     Palliative Care.--
       (1) Evaluation.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall conduct an evaluation of geographic 
     areas and populations underserved by hospice and hospital-
     based palliative care to identify potential barriers to 
     access.
       (2) Report.--Not later than December 31, 2012, the 
     Secretary shall report to Congress, on the evaluation 
     conducted under subsection (a) together with recommendations 
     for such legislation and administrative action as the 
     Secretary determines appropriate to address barriers to 
     access to hospice and hospital-based palliative care.
       (b) Evaluation of Awareness and Use of Hospice Respite Care 
     Under Medicare, Medicaid, and CHIP.--
       (1) Evaluation.--The Secretary, acting through the Director 
     of the Centers for Medicare and Medicaid Services, shall 
     evaluate the awareness and use of hospice respite care by 
     informal caregivers of beneficiaries under Medicare, 
     Medicaid, and CHIP.
       (2) Report.--Not later than December 31, 2010, the 
     Secretary shall report to Congress, on the evaluation 
     conducted under subsection (a) together with recommendations 
     for such legislation and administrative action as the 
     Secretary determines appropriate to increase awareness or use 
     of hospice respite care under Medicare, Medicaid, and CHIP.

                    Subtitle C--Quality Improvement

     SEC. 241. PATIENT SATISFACTION SURVEYS.

       Not later than January 1, 2012, the Secretary, acting 
     through the Administrator of the Centers for Medicare & 
     Medicaid Services, shall establish a mechanism for--
       (1) collecting information from patients (or their health 
     care proxies or families members in the event patients are 
     unable to speak for themselves) in relevant provider settings 
     regarding their care at the end of life; and
       (2) incorporating such information in a timely manner into 
     mechanisms used by the Administrator to provide quality of 
     care information to consumers, including the Hospital Compare 
     and Nursing Home Compare websites maintained by the 
     Administrator.

     SEC. 242. DEVELOPMENT OF CORE END-OF-LIFE CARE QUALITY 
                   MEASURES ACROSS EACH RELEVANT PROVIDER SETTING.

       (a) In General.--The Secretary, acting through the 
     Administrator of the Agency for Healthcare Research and 
     Quality (in this section referred to as the 
     ``Administrator'') and in consultation with the Director of 
     the National Institutes of Health, shall require specific 
     end-of-life quality measures for each relevant provider 
     setting, as identified by the Administrator, in accordance 
     with the requirements of subsection (b).
       (b) Requirements.--For purposes of subsection (a), the 
     requirements specified in this subsection are the following:
       (1) Selection of the specific measure or measures for an 
     identified provider setting shall be--
       (A) based on an assessment of what is likely to have the 
     greatest positive impact on quality of end-of-life care in 
     that setting; and
       (B) made in consultation with affected providers and public 
     and private organizations, that have developed such measures.
       (2) The measures may be structure-oriented, process-
     oriented, or outcome-oriented, as determined appropriate by 
     the Administrator.
       (3) The Administrator shall ensure that reporting 
     requirements related to such measures are imposed consistent 
     with other applicable laws and regulations, and in a manner 
     that takes into account existing measures, the needs of 
     patient populations, and the specific services provided.
       (4) Not later than--
       (A) April 1, 2011, the Secretary shall disseminate the 
     reporting requirements to all affected providers; and
       (B) April 1, 2012, initial reporting relating to the 
     measures shall begin.

     SEC. 243. ACCREDITATION OF HOSPITAL-BASED PALLIATIVE CARE 
                   PROGRAMS.

       (a) In General.--The Secretary, acting through the Director 
     of the Agency for Healthcare Research and Quality, shall 
     designate a public or private agency, entity, or organization 
     to develop requirements, standards, and procedures for 
     accreditation of hospital-based palliative care programs.
       (b) Reporting.--Not later than January 1, 2012, the 
     Secretary shall prepare and submit a report to Congress on 
     the proposed accreditation process for hospital-based 
     palliative care programs.
       (c) Accreditation.--Not later than July 1, 2012, the 
     Secretary shall--
       (1) establish and promulgate standards and procedures for 
     accreditation of hospital-based palliative care programs; and
       (2) designate an agency, entity, or organization that shall 
     be responsible for certifying such programs in accordance 
     with the standards established under paragraph (1).
       (d) Definitions.--For the purposes of this section:
       (1) The term ``hospital-based palliative care program'' 
     means a hospital-based program that is comprised of an 
     interdisciplinary team that specializes in providing 
     palliative care services and consultations in a variety of 
     health care settings, including hospitals, nursing homes, and 
     home and community-based services.
       (2) The term ``interdisciplinary team'' means a group of 
     health care professionals (consisting of, at a minimum, a 
     doctor, a nurse, and a social worker) that have received 
     specialized training in palliative care.

     SEC. 244. SURVEY AND DATA REQUIREMENTS FOR ALL MEDICARE 
                   PARTICIPATING HOSPICE PROGRAMS.

       (a) Hospice Surveys.--Section 1861(dd) of the Social 
     Security Act (42 U.S.C. 1395x(dd)) is amended by adding at 
     the end the following new paragraph:
       ``(6) In accordance with the recommendations of the 
     Medicare Payment Advisory Commission contained in the March 
     2009 report entitled `Report to Congress: Medicare Payment 
     Policy', the Secretary shall establish, effective July 1, 
     2010, the following survey requirements for hospice programs:
       ``(A) Any hospice program seeking initial certification 
     under this title on or after that date shall be subject to an 
     initial survey by an appropriate State or local agency, or an 
     approved accreditation agency, not later than 6 months after 
     the program first seeks such certification.
       ``(B) All hospice programs certified for participation 
     under this title shall be subject to a standard survey by an 
     appropriate State or local agency, or an approved 
     accreditation agency, at least every 3 years after initially 
     being so certified.''.
       (b) Required Hospice Resource Inputs Data.--Section 
     1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)), as 
     amended by subsection (a), is amended--
       (1) in paragraph (3)--
       (A) in subparagraph (F), by striking ``and'' at the end;
       (B) by redesignating subparagraph (G) as subparagraph (H); 
     and
       (C) by inserting after subparagraph (F) the following new 
     subparagraph:
       ``(G) to comply with the reporting requirements under 
     paragraph (7); and''; and
       (2) by adding at the end the following new paragraph:
       ``(7)(A) In accordance with the recommendations of the 
     Medicare Payment Advisory Commission for additional data (as

[[Page S5872]]

     contained in the March 2009 report entitled `Report to 
     Congress: Medicare Payment Policy'), beginning January 1, 
     2011, a hospice program shall report to the Secretary, in 
     such form and manner, and at such intervals, as the Secretary 
     shall require, the following data with respect to each 
     patient visit:
       ``(i) Visit type (such as admission, routine, emergency, 
     education for family, other).
       ``(ii) Visit length.
       ``(iii) Professional or paraprofessional disciplines 
     involved in the visit, including nurse, social worker, home 
     health aide, physician, nurse practitioner, chaplain or 
     spiritual counselor, counselor, dietician, physical 
     therapist, occupational therapist, speech language 
     pathologist, music or art therapist, and including 
     bereavement and support services provided to a family after a 
     patient's death.
       ``(iv) Drugs and other therapeutic interventions provided.
       ``(v) Home medical equipment and other medical supplies 
     provided.
       ``(B) In collecting the data required under subparagraph 
     (A), the Secretary shall ensure that the data are reported in 
     a manner that allows for summarized cross-tabulations of the 
     data by patients' terminal diagnoses, lengths of stay, age, 
     sex, and race.''.

       Subtitle D--Additional Reports, Research, and Evaluations

     SEC. 251. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.

       Part E of title IV of the Public Health Service Act (42 
     U.S.C. 287 et seq.) is amended by adding at the end the 
     following:

    ``Subpart 7--National Center on Palliative and End-of-Life Care

     ``SEC. 485J. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE 
                   CARE.

       ``(a) Establishment.--Not later than July 1, 2011, there 
     shall be established within the National Institutes of 
     Health, a National Center on Palliative and End-of-Life Care 
     (referred to in this section as the `Center').
       ``(b) Purpose.--The general purpose of the Center is to 
     conduct and support research relating to palliative and end-
     of-life care interventions and approaches.
       ``(c) Activities.--The Center shall--
       ``(1) develop and continuously update a research agenda 
     with the goal of--
       ``(A) providing a better biomedical understanding of the 
     end of life; and
       ``(B) improving the quality of care and life at the end of 
     life; and
       ``(2) provide funding for peer-review-selected extra- and 
     intra-mural research that includes the evaluation of 
     existing, and the development of new, palliative and end-of-
     life care interventions and approaches.''.

     SEC. 252. NATIONAL MORTALITY FOLLOWBACK SURVEY.

       (a) In General.--Not later than December 31, 2010, and 
     annually thereafter, the Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall renew and conduct the National Mortality Followback 
     Survey (referred to in this section as the ``Survey'') to 
     collect data on end-of-life care.
       (b) Purpose.--The purpose of the Survey shall be to gain a 
     better understanding of current end-of-life care in the 
     United States.
       (c) Questions.--
       (1) In general.--In conducting the Survey, the Director of 
     the Centers for Disease Control and Prevention shall, at a 
     minimum, include the following questions with respect to the 
     loved one of a respondent:
       (A) Did he or she have an advance directive, and if so, 
     when it was completed.
       (B) Did he or she have an order for life-sustaining 
     treatment, and if so, when was it completed.
       (C) Did he or she have a durable power of attorney, and if 
     so, when it was completed.
       (D) Had he or she discussed his or her wishes with loved 
     ones, and if so, when.
       (E) Had he or she discussed his or her wishes with his or 
     her physician, and if so, when.
       (F) In the opinion of the respondent, was he or she 
     satisfied with the care he or she received in the last year 
     of life and in the last week of life.
       (G) Was he or she cared for by hospice, and if so, when.
       (H) Was he or she cared for by palliative care specialists, 
     and if so, when.
       (I) Did he or she receive effective pain management (if 
     needed).
       (J) What was the experience of the main caregiver 
     (including if such caregiver was the respondent), and whether 
     he or she received sufficient support in this role.
       (2) Additional questions.--Additional questions to be asked 
     during the Survey shall be determined by the Director of the 
     Centers for Disease Control and Prevention on an ongoing 
     basis with input from relevant research entities.

     SEC. 253. DEMONSTRATION PROJECTS FOR USE OF TELEMEDICINE 
                   SERVICES IN ADVANCE CARE PLANNING.

       (a) In General.--Not later than July 1, 2013, the Secretary 
     shall establish a demonstration program to reimburse eligible 
     entities for costs associated with the use of telemedicine 
     services (including equipment and connection costs) to 
     provide advance care planning consultations with 
     geographically distant physicians and their patients.
       (b) Duration.--The demonstration project under this section 
     shall be conducted for at least a 3-year period.
       (c) Definitions.--For purposes of this section:
       (1) The term ``eligible entity'' means a physician or an 
     advance practice nurse who provides services pursuant to a 
     hospital-based palliative care program (as defined in section 
     262(d)(1)).
       (2) The term ``geographically distant'' has the meaning 
     given that term by the Secretary for purposes of conducting 
     the demonstration program established under this section.
       (3) The term ``telemedicine services'' means a service or 
     consultation provided via telecommunication equipment that 
     allows an eligible entity to exchange or discuss medical 
     information with a patient or a health care professional at a 
     separate location through real-time videoconferencing, or a 
     similar format, for the purpose of providing health care 
     diagnosis and treatment.
       (d) Funding.--There are authorized to be appropriated to 
     the Secretary such sums as may be necessary to carry out this 
     section.

     SEC. 254. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND ABUSE.

       In accordance with the recommendations of the Medicare 
     Payment Advisory Commission for additional data (as contained 
     in the March 2009 report entitled ``Report to Congress: 
     Medicare Payment Policy''), the Secretary shall direct the 
     Office of the Inspector General of the Department of Health 
     and Human Services to investigate, not later than January 1, 
     2012, the following with respect to hospice benefit under 
     Medicare, Medicaid, and CHIP:
       (1) The prevalence of financial relationships between 
     hospices and long-term care facilities, such as nursing 
     facilities and assisted living facilities, that may represent 
     a conflict of interest and influence admissions to hospice.
       (2) Differences in patterns of nursing home referrals to 
     hospice.
       (3) The appropriateness of enrollment practices for 
     hospices with unusual utilization patterns (such as high 
     frequency of very long stays, very short stays, or enrollment 
     of patients discharged from other hospices).
       (4) The appropriateness of hospice marketing materials and 
     other admissions practices and potential correlations between 
     length of stay and deficiencies in marketing or admissions 
     practices.

     SEC. 255. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO 
                   ADVANCE DIRECTIVES.

       Not later than January 1, 2012, the Comptroller General of 
     the United States shall conduct a study of the extent to 
     which providers comply with advance directives under the 
     Medicare and Medicaid programs and shall submit a report to 
     Congress on the results of such study, together with such 
     recommendations for administrative or legislative changes as 
     the Comptroller General determines appropriate.
                                 ______
                                 
      By Mr. REID (for Mr. Rockefeller (for himself and Ms. Snowe)):
  S. 1151. A bill to amend part A of title IV of the Social Security 
Act to require the Secretary of Health and Human Services to conduct 
research on indicators of child well-being; to the Committee on 
Finance.
  Mr. ROCKEFELLER. Mr. President, today I am pleased to introduce with 
my distinguished colleague Senator Olympia Snowe, bipartisan 
legislation known as the State Child Well-Being Research Act of 2009. 
Companion legislation has already been introduced in the House by 
Congressmen Fattah and Camp. This bill is designed to enhance child 
well-being by requiring the Secretary of Health and Human Services to 
facilitate the collection of state-specific data based on a defined set 
of indicators. The well-being of children is important to both national 
and State governments. Therefore, data collection is a priority that 
cannot be ignored if we hope to make informed decisions on public 
policy.
  In 1996, Congress passed bold legislation, which I supported to 
dramatically change our welfare system. The driving force behind this 
reform was to promote the work and self-sufficiency of families and to 
provide the flexibility to States necessary to achieve these goals. 
States, which is where most child and family legislation takes place, 
have used this flexibility to design different programs that work 
better for the families who rely on them. The design and benefits 
available under other programs that serve children, ranging from the 
Children Health Insurance Program, CHIP, to child welfare services, can 
vary widely among States.
  It is obvious that in order for policy makers to evaluate child well-
being, we need state-specific data on child well-being to measure the 
results. Current surveys provide minimal data on some important 
indicators of child well-being, but insufficient data is available on 
low-income families, geographic variation, and young children. 
Additionally, the information is not provided in a timely manner, which 
impedes legislators' ability to effectively measure child well-being 
and design effective programs to support our children.

[[Page S5873]]

  The State Child Well-Being Research Act of 2009 is intended to fill 
this information gap by collecting up-to-date, State-specific data that 
can be used by policymakers, researchers, and child advocates to assess 
the well-being of children. As we strive to promote quality programs, 
we need basic benchmarks to measure outcomes. Our bill would require 
that a survey examine the physical and emotional health of children, 
adequately represent the experiences of families in individual states, 
be consistent across states, be collected annually, articulate results 
in easy to understand terms, and focus on low-income children and 
families. This legislation also establishes an advisory committee, 
consisting of a panel of experts who specialize in survey methodology 
and indicators of child well-being, and the application of this data to 
ensure that the purpose is being achieved.
  Further, this bill avoids some of the problems in the current system 
by making data files easier to use and more readily available to the 
public. As a result, the information will be more useful for policy-
makers managing welfare reform and programs for children and families. 
Finally, this legislation also offers the potential for the Health and 
Human Service Department to partner with private charitable 
foundations, like the Annie E. Casey Foundations, which has already 
expressed an interest in forming a partnership to provide outreach, 
support and a guarantee that the data collected would be broadly 
disseminated. This type of public-private partnership helps to leverage 
additional resources for children and families and increases the 
study's impact. Given the tight budget we face, partnerships make sense 
to meet this essential need.
  I hope my colleagues review this legislation carefully and choose to 
support it so that Federal and state policy makers and advocates have 
the information necessary to make good decisions for children.
  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. 1151

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``State Child Well-Being 
     Research Act of 2009''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) The well-being of children is a paramount concern for 
     our Nation and for every State, and most programs for 
     children and families are managed at the State or local 
     level.
       (2) Child well-being varies over time and across social, 
     economic, and geographic groups, and can be affected by 
     changes in the circumstances of families, by the economy, by 
     the social and cultural environment, and by public policies 
     and programs at the Federal, State, and local level.
       (3) States, including small States, need information about 
     child well-being that is specific to their State and that is 
     up-to-date, cost-effective, and consistent across States and 
     over time.
       (4) Regular collection of child well-being information at 
     the State level is essential so that Federal and State 
     officials can track child well-being over time.
       (5) Information on child well-being is necessary for all 
     States, particularly small States that do not have State-
     level data in other federally supported databases. 
     Information is needed on the well-being of all children, not 
     just children participating in Federal programs.
       (6) Telephone surveys of parents represent a relatively 
     cost-effective strategy for obtaining information on child 
     well-being at the State level for all States, including small 
     States, and can be conducted alone or in mixed mode strategy 
     with other survey techniques.
       (7) Data from telephone surveys of the population are 
     currently used to monitor progress toward many important 
     national goals, including immunization of preschool children 
     with the National Immunization Survey, and the identification 
     of health care issues of children with special needs with the 
     National Survey of Children with Special Health Care Needs.
       (8) A State-level telephone survey, alone or in combination 
     with other techniques, can provide information on a range of 
     topics, including children's social and emotional 
     development, education, health, safety, family income, family 
     employment, and child care. Information addressing marriage 
     and family structure can also be obtained for families with 
     children. Information obtained from such a survey would not 
     be available solely for children or families participating in 
     programs but would be representative of the entire State 
     population and consequently, would inform welfare 
     policymaking on a range of important issues, such as income 
     support, child care, child abuse and neglect, child health, 
     family formation, and education.

     SEC. 3. RESEARCH ON INDICATORS OF CHILD WELL-BEING.

       Section 413 of the Social Security Act (42 U.S.C. 613) is 
     amended by adding at the end the following:
       ``(k) Indicators of Child Well-Being.--
       ``(1) Renaming of survey.--On and after the date of the 
     enactment of this subsection, the National Survey of 
     Children's Health conducted by the Director of the Maternal 
     and Child Health Bureau of the Health Resources and Services 
     Administration shall be known as the `Survey of Children's 
     Health and Well-Being'.
       ``(2) Modification of survey to include matters relating to 
     child well-being.--The Secretary shall modify the survey so 
     that it may be used to better assess child well-being, as 
     follows:
       ``(A) New indicators included.--The indicators with respect 
     to which the survey collects information shall include 
     measures of child-well-being related to the following:
       ``(i) Education.
       ``(ii) Social and emotional development.
       ``(iii) Physical and mental health and safety.
       ``(iv) Family well-being, such as family structure, income, 
     employment, child care arrangements, and family 
     relationships.
       ``(B) Collection requirements.--The data collected with 
     respect to the indicators developed under subparagraph (A) 
     shall be--
       ``(i) statistically representative at the State and 
     national level;
       ``(ii) consistent across States, except that data shall be 
     collected in States other than the 50 States and the District 
     of Columbia only if technically feasible;
       ``(iii) collected on an annual or ongoing basis;
       ``(iv) measured with reliability;
       ``(v) current;
       ``(vi) over-sampled (if feasible), with respect to low-
     income children and families, so that subgroup estimates can 
     be produced by a variety of income categories (such as for 
     50, 100, and 200 percent of the poverty level, and for 
     children of varied ages, such as 0-5, 6-11, 12-17, and (if 
     feasible) 18-21 years of age); and
       ``(vii) made publicly available.
       ``(C) Other requirements.--
       ``(i) Publication.--The data collected with respect to the 
     indicators developed under subparagraph (A) shall be 
     published as absolute numbers and expressed in terms of rates 
     or percentages.
       ``(ii) Availability of data.--A data file shall be made 
     available to the public, subject to confidentiality 
     requirements, that includes the indicators, demographic 
     information, and ratios of income to poverty.
       ``(iii) Sample sizes.--Sample sizes used for the collected 
     data shall be adequate for microdata on the categories 
     included in subparagraph (B)(vi) to be made publicly 
     available, subject to confidentiality requirements.
       ``(D) Consultation.--
       ``(i) In general.--In developing the indicators under 
     subparagraph (A) and the means to collect the data required 
     with respect to the indicators, the Secretary shall consult 
     and collaborate with a subcommittee of the Federal 
     Interagency Forum on Child and Family Statistics, which shall 
     include representatives with expertise on all the domains of 
     child well-being described in subparagraph (A). The 
     subcommittee shall have appropriate staff assigned to work 
     with the Maternal and Child Health Bureau during the design 
     phase of the survey.
       ``(ii) Duties.--The Secretary shall consult with the 
     subcommittee referred to in clause (i) with respect to the 
     design, content, and methodology for the development of the 
     indicators under subparagraph (A) and the collection of data 
     regarding the indicators, and the availability or lack 
     thereof of similar data through other Federal data collection 
     efforts.
       ``(iii) Costs.--Costs incurred by the subcommittee with 
     respect to the development of the indicators and the 
     collection of data related to the indicators shall be treated 
     as costs of the survey.
       ``(3) Advisory panel.--
       ``(A) Establishment.--The Secretary, in consultation with 
     the Federal Interagency Forum on Child and Family Statistics, 
     shall establish an advisory panel of experts to make 
     recommendations regarding--
       ``(i) the additional matters to be addressed by the survey 
     by reason of this subsection; and
       ``(ii) the methods, dissemination strategies, and 
     statistical tools necessary to conduct the survey as a whole.
       ``(B) Membership.--
       ``(i) In general.--The advisory panel established under 
     subparagraph (A) of this paragraph shall include experts on 
     each of the domains of child well-being described in 
     paragraph (2)(A), experts on child indicators, experts from 
     State agencies and from nonprofit organizations that use 
     child indicator data at the State level, and experts on 
     survey methodology.
       ``(ii) Deadline.--The members of the advisory panel shall 
     be appointed not later than 2 months after the date of the 
     enactment of this subsection.
       ``(C) Meetings.--The advisory panel established under 
     subparagraph (A) shall meet--

[[Page S5874]]

       ``(i) at least 3 times during the first year after the date 
     of enactment of this subsection; and
       ``(ii) annually thereafter for the 4 succeeding years.
       ``(4) Authorization of appropriations.--There are 
     authorized to be appropriated for each of fiscal years 2010 
     through 2014, $20,000,000 for the purpose of carrying out 
     this subsection.''.

     SEC. 4. GAO REPORT ON COLLECTION AND REPORTING OF DATA ON 
                   DEATHS OF CHILDREN IN FOSTER CARE.

       (a) In General.--Within 1 year after the date of the 
     enactment of this Act, the Comptroller General of the United 
     States shall conduct a study to determine, and submit to the 
     Congress a written report on the adequacy of, the methods of 
     collecting and reporting data on deaths of children in the 
     child welfare system.
       (b) Matters to Be Considered.--In the study, the 
     Comptroller General shall, for each year for which data are 
     available, determine--
       (1) the number of children eligible for services or 
     benefits under part B or E of title IV of the Social Security 
     Act who States reported as having died due to abuse or 
     neglect;
       (2) the number of children so eligible who died due to 
     abuse or neglect but were not accounted for in State reports; 
     and
       (3) the number of children in State child welfare systems 
     who died due to abuse or neglect and whose deaths are not 
     included in the data described in paragraph (1) or (2).
       (c) Recommendations.--In the report, the Comptroller 
     General shall include recommendations on how surveys of 
     children by the Federal Government and by State governments 
     can be improved to better capture all data on the death of 
     children in the child welfare system, so that the Congress 
     can work with the States to develop better policies to 
     improve the well-being of children and reduce child deaths.
                                 ______
                                 
      By Mr. REID (for Mr. Kennedy (for himself, Mr. Dodd, Mr. Harkin, 
        Ms. Mikulski, Mrs. Murray, Mr. Sanders, Mr. Brown, Mr. Casey, 
        Mr. Inouye, Mr. Levin, Mr. Kerry, Mr. Akaka, Mrs. Boxer!, Mr. 
        Feingold, Mr. Durbin, Mr. Johnson, Mr. Schumer, Mr. Lautenberg, 
        Mr. Menendez, Mr. Burr, and Mrs. Gillibrand)):
  S. 1152. A bill to allow Americans to earn paid sick time so that 
they can address their own health needs and the health needs and the 
health needs of their families; to the Committee on Health, Education, 
Labor, and Pensions.
  Mr. KENNEDY. Mr. President, in this turbulent economy, working 
families are facing enormous challenges. Too many families are living 
paycheck to paycheck, just one layoff or health crisis away from 
disaster. Now more than ever, workers are struggling to balance the 
demands of their jobs and their families. When a sickness or health 
problem arises, these challenges can easily become insurmountable.
  Unfortunately, almost half of all private sector workers--including 
79 percent of low-wage workers--have no paid sick days they can use to 
care for themselves or a sick family member. For these workers, taking 
a day off to care for their own health or a sick child means losing a 
much-needed paycheck, or even putting their jobs in danger. In a recent 
survey, 1 in 6 workers reported that they or a family member have been 
fired, punished or threatened with termination for taking time off 
because of their own illness or to care for a sick relative.
  Workers can't afford to take that kind of risk now. Losing even one 
paycheck can mean falling behind on bills, foregoing needed medicines, 
or skipping meals. As a result, many employees continue to go to work 
when they are ill, and send their children to school or day care sick, 
because it's the only way to make ends meet.
  The lack of paid sick day is not just a crisis for individual 
families--it is a public health crisis as well. The current flu 
outbreak provides a compelling illustration. To prevent the spread of 
the virus, the World Health Organization, the Center for Disease 
Control, and numerous state and local public health officials urged 
people to stay home from work or school if they flu-like symptoms. 
Strong scientific evidence proves that this is one of the best ways to 
prevent the spread of disease and protect the public health.
  But without paid sick days, following this sound advice is often 
impossible--millions of employees want to do the right thing and stay 
home, but our current laws just do not protect them. The Family and 
Medical Leave Act enables workers to take time off for serious health 
conditions, but only about half of today's workers are covered by the 
act, and millions more can not take advantage of it because this leave 
is unpaid.
  Hardworking Americans should not have to make these impossible 
choices. That's why Senator Dodd, Representative Rosa DeLauro and I are 
introducing the Healthy Families Act, which will enable workers to take 
up to 56 hours, or about 7 days, of paid sick leave each year. 
Employees can use this time to stay home and get well when they are 
ill, to care for a sick family member, to obtain preventive or 
diagnostic treatment, or to seek help if they are victims of domestic 
violence.
  This important legislation will provide needed security for working 
families struggling to balance the jobs they need and the families they 
love. It will improve public health and reduce health costs by 
preventing the spread of disease and giving employees the access they 
need to obtain preventive care. It will also help victims of domestic 
violence to protect their families and their futures.
  In addition, the legislation will benefit businesses by decreasing 
employee turnover, and improving productivity. ``Presenteeism''--sick 
workers coming to work and infecting their colleagues instead of 
staying at home--costs our economy $180 billion annually in lost 
productivity. For employers, the cost averages $255 per employee per 
year, and exceeds the cost of absenteeism and medical and disability 
benefits. The lack of paid sick days also leads to higher employee 
turnover, especially for low-wage workers. When the benefits of the 
Healthy Families Act are weighed against its costs, providing paid sick 
days will actually save American businesses up to $9 billion a year by 
eliminating these productivity losses and reducing turnover.
  Above all, enabling workers to earn paid sick time to care for 
themselves and their families is a matter of fundamental fairness. 
Every worker has had to miss days of work because of illness. Every 
child gets sick and needs a parent at home to take care of them. And 
all hardworking Americans deserve the chance to take care of their 
families without putting their jobs or their health on the line.
  It is long past time for our laws to deal with these difficult 
choices that working men and women face every day. As President Obama 
has said, ``Nobody in America should have to choose between keeping 
their jobs and caring for a sick child.'' I urge all of my colleagues 
to join in supporting the Healthy Families Act.

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