[Congressional Record Volume 164, Number 105 (Friday, June 22, 2018)]
[House]
[Pages H5561-H5572]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SUBSTANCE USE-DISORDER PREVENTION THAT PROMOTES OPIOID RECOVERY AND
TREATMENT FOR PATIENTS AND COMMUNITIES ACT
The Committee resumed its sitting.
Amendment No. 2 Offered by Mr. Dunn
The Acting CHAIR (Mr. Poe of Texas). It is now in order to consider
amendment No. 2 printed in part B of House Report 115-766.
Mr. DUNN. Mr. Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:
Page 93, strike lines 18 through 22 and insert the
following:
(2) in subclause (II), by striking ``during the period
beginning on the date of enactment of the Comprehensive
Addiction and Recovery Act of 2016 and ending on October 1,
2021,''.
Page 93, strike line 23 and all that follows through page
94, line 17.
Page 94, line 18, strike ``(e)'' and insert ``(c)''.
The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Florida (Mr. Dunn) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from Florida.
Mr. DUNN. Mr. Chair, I rise in support of my amendment to H.R. 6. I
am grateful for the opportunity to speak about it.
My amendment strikes language that would expand the classes of
healthcare workers who would be authorized to dispense narcotics for
narcotic treatment.
Let me be clear at the outset. H.R. 6 is, in large part, a great
bill; however, as currently written, it allows nurse specialists, nurse
midwives, and nurse anesthetists to prescribe buprenorphine. I believe
this is a significant and impulsive expansion of prescribing authority.
Allowing more providers with less clinical experience to provide
buprenorphine, a highly addictive opioid, opens up dangerous new
potential for increased opioid abuse. The point of H.R. 6 is to
decrease opioid abuse, but this provision increases the potential for
abuse and vastly increases the supply of a dangerous opioid that is one
of the major causes of opioid overdose and death in Europe.
Mr. Chair, I appreciate the opportunity to bring these concerns to
light in this amendment.
Mr. Chair, I include in the Record a letter in support of my
amendment from The OTP Consortium.
The OTP Consortium,
June 19, 2018.
Hon. Greg Walden,
Chairman, Committee on Energy and Commerce, House of
Representatives, Washington, DC.
Hon. Kevin Brady,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
Hon. Frank Pallone, Jr.,
Ranking Member, Committee on Energy and Commerce, House of
Representatives, Washington, DC.
Hon. Richard Neal,
Ranking Member, Committee on Ways and Means, House of
Representatives, Washington, DC.
Dear Chairmen Walden and Brady and Ranking Members Pallone
and Neal: On behalf of the Opioid Treatment Program (OTP)
Consortium we would like to offer our support for H.R. 6, the
Substance Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment (SUPPORT) for Patients and Communities
Act. In particular, we strongly support Section 207 which
would provide Medicare beneficiaries with lifesaving
Medication-Assisted Treatment (MAT) for opioid use disorder
(OUD) in the highly-effective OTP setting. This policy was
introduced by Ranking Member Neal and Congressman George
Holding as part of H.R. 5776, the Medicare and Opioid Safe
Treatment (MOST) Act of 2018. The OTP Consortium is comprised
of nearly 350 OTPs across the country that provide care to
more than 140,000 patients daily in 37 states, including at
our 22 facilities in Massachusetts, 16 facilities in Texas,
nine facilities in Oregon, and two facilities in New Jersey.
OTPs are highly-regulated, highly-structured, comprehensive
treatment programs that provide MAT--which the National
Institutes of Health states is the most effective solution to
treat OUD. OTPs are the only provider where patients are
guaranteed to receive MAT--including individual and group
counseling, random toxicology screens, medication, and other
supportive services such as case management, primary care,
mental health services, HIV and Hepatitis C testing and more.
Medicare beneficiaries have the highest and fastest growing
rate of OUD, yet they do not currently have coverage for the
most effective form of treatment--H.R. 6 provides such
coverage. More than 300,000 Medicare beneficiaries have been
diagnosed with OUD--your legislation could end up saving
their lives and many more. Medicare hospitalizations due to
complications caused by opioid abuse or misuse increased 10%
every year from 1993 to 2012--your bill would help reverse
this alarming trend.
We do, however, have concerns about the policies contained
in Section 303. While we are pleased that the 275-patient
threshold was not codified, we do not support expanding or
making permanent buprenorphine prescribing authority to non-
physician providers before policymakers can fully analyze the
data resulting from the critical questions asked in
subsection (e). Americans need effective treatment and
decades of evidence and outcomes show that medication simply
assists the other treatment interventions. Medication should
never be the sole aspect of treating SUD--thus the term
Medication-Assisted Treatment. Office-based practices that
focus on medication alone run the risk of becoming the next-
generation pill mill. We hope that Congress will revisit
office-based buprenorphine prescribing thresholds once this
quality assessment has been completed and it can be
determined whether or not patients are indeed truly receiving
MAT in these settings. Improving access to buprenorphine is
important, but it must be paired with the evidence-based MAT
services that are proven to lead to recovery.
We support H.R. 6 and stand ready to work with you see that
this critical Medicare OTP benefit is signed into law,
without delay.
Sincerely,
Peter Morris,
Division President, Acadia Healthcare.
Alex Dodd,
CEO, Aegis Treatment Centers, LLC.
David White, Ph.D.,
CEO, BayMark Health Service.
Jay Higham,
CEO, Behavioral Health Group.
John Steinbrun,
CEO, New Season.
Mr. DUNN. Mr. Chair, I reserve the balance of my time.
Mr. WALDEN. Mr. Chair, I claim time in opposition to the amendment.
The Acting CHAIR. The gentleman from Oregon is recognized for 5
minutes.
Mr. WALDEN. Mr. Chair, I certainly appreciate Dr. Dunn and the good
work that he has done on many of these issues, and I also appreciate
his willingness to withdraw his amendment.
[[Page H5562]]
As a result of our committee process and various member conversations
we have had, we have reached bipartisan compromise on the underlying
bill on the issue of concern to Mr. Dunn.
I understand that thoughtful Members can find themselves on different
sides of an issue at different times, and I certainly respect the
gentleman's position. That being said, we believe our underlying policy
represents a fair middle ground, and it ensures rigorous analysis on
the issue going forward.
Mr. Chair, I appreciate the gentleman from Florida withdrawing the
amendment.
Mr. Chair, I yield 2\1/2\ minutes to the gentleman from New York (Mr.
Tonko).
Mr. TONKO. Mr. Chair, I thank Chairman Walden for yielding.
Although I know my colleague plans to withdraw, I rise in opposition
to this amendment, and I just want to articulate a bit of my reasoning.
I think my colleagues and I both share the same goal of safely
expanding access to addiction treatment. Where we differ is that I
believe that the provisions in H.R. 6 expanding buprenorphine
prescribing privileges to advanced practice nurses meet that test.
We all know that there is a dire need for expanded treatment capacity
to meet the demands of this current epidemic. As many as 40 percent of
counties across the country lack even a single provider that is able to
offer buprenorphine. Advanced practice nurses play an outsized role in
providing care in rural America, and H.R. 6 will help expand addiction
treatment capacity into these communities where it is most needed.
Expanding buprenorphine prescribing privileges to APRNs is supported
by medical groups that serve on the front lines of this epidemic, such
as the American Society for Addiction Medicine and the American
Congress of Obstetricians and Gynecologists.
All advanced practice nurses who wish to prescribe medication-
assisted treatment would have to receive a special waiver from the DEA
and would have to undergo three times as much specialized addiction
training as their physician colleagues.
In addition, in order to receive a waiver, practitioners are required
to be able to provide appropriate counseling and ancillary services
that are the hallmark of high-quality addiction treatment. All APRNs
wishing to prescribe buprenorphine would still be subject to State laws
regarding prescription authority, scope of practice, and collaboration
or supervision requirements with a physician.
While I understand that providing addiction treatment is a complex
and nuanced area of medicine with potential complications if done
poorly, I would point out that we don't restrict advanced practice
registered nurses in Federal law from providing such high-risk services
as delivering babies, administering anesthesia, or prescribing as many
opioids as they wish. Why would we want to maintain an outdated barrier
in Federal law that prevents these practitioners from being part of the
solution to the opioid epidemic?
So in closing, I appreciate that my colleagues are withdrawing this
amendment today, and I would urge that, as we move forward toward a
potential conference committee, we continue to recognize the role that
advanced practice nurses can play in addressing this epidemic.
Mr. WALDEN. Mr. Chairman, I reserve the balance of my time.
Mr. DUNN. Mr. Chair, I yield 1 minute to the gentleman from Tennessee
(Mr. Roe), the chairman of the Veterans' Affairs Committee.
Mr. ROE of Tennessee. Mr. Chair, I thank the gentleman for yielding.
As a practicing physician for over 30 years, I have incredible
respect for nurses and the work they do. I married a nurse. Some of the
best employees I have worked with were nurses. I could not appreciate
the job they do more, Mr. Chair, but care for patients is better
directed with physician oversight.
Even with my training, we need fewer doctors like me writing these
prescriptions and more physicians trained in pain management. The
American Society of Addiction Medicine is establishing approved
fellowships in training in addiction medicine today.
Expanding the scope of practice for nonphysician providers to
dispense drugs like buprenorphine goes in the wrong direction, in my
opinion.
There are many factors that contribute to the explosive growth in
opioid use, but clearly a big factor was the lack of knowledge about
opioids' addictive qualities. I would argue that we have a similar lack
of knowledge about buprenorphine today, and allowing providers who have
less training and less knowledge about these substances exponentially
increases the chances of abuse in these substances.
{time} 1045
If we remove the most highly-trained specialist from administration
of buprenorphine, I fear that all the good we are trying to do in this
bill could be negated.
The Acting CHAIR. The time of the gentleman has expired.
Mr. DUNN. I yield the gentleman an additional 1 minute.
Mr. ROE of Tennessee. There are plenty of provisions to support in
this underlying bill. It is a good bill, but section 303 is not one of
them.
I encourage my colleagues to support the amendment.
Mr. WALDEN. Mr. Chairman, I continue to reserve the balance of my
time.
Mr. DUNN. Mr. Chairman, I yield 1 minute to the gentleman from Kansas
(Mr. Marshall).
Mr. MARSHALL. Mr. Chairman, I thank Dr. Dunn for leading this
amendment.
I had an over three-decade experience and great working relationship
with physician assistants, nurse practitioners, as well as nurse
anesthetists. I believe one of the secrets to that great work that we
did was the collaboration between us and how we worked together.
I firmly believe that whenever narcotics are involved, there needs to
be a very close working relationship between the supervising physician
and these other groups and societies. As narcotic and opioid abuse has
become a national crisis, we need to be working even more closely
together so as not to exacerbate the problem.
Mr. WALDEN. Mr. Chairman, I yield back the balance of my time.
Mr. DUNN. Mr. Chair, buprenorphine was introduced in Finland in 1997,
and now it has become the most widely-abused opioid in that country.
Buprenorphine can kill people. It does kill people. And office-based
practices involving merely prescribing buprenorphine run a large risk
of harming patients, not helping them to recover.
In closing, I want to thank you for working with me on this
amendment, and I thank Chairman Walden for his gracious commitment to
continue to examine.
I yield back the balance of my time
Mr. Chairman, I ask unanimous consent to withdraw my amendment.
The Acting CHAIR. Is there objection to the request of the gentleman
from Florida?
There was no objection.
The Acting CHAIR. The amendment is withdrawn.
Amendment No. 3 Offered by Mr. Barton
The Acting CHAIR. It is now in order to consider amendment No. 3
printed in part B of House Report 115-766.
Mr. BARTON. Mr. Chairman, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:
At the end of title III, insert the following new section:
SEC. 304. HIGH-QUALITY, EVIDENCE-BASED OPIOID ANALGESIC
PRESCRIBING GUIDELINES AND REPORT.
(a) Guidelines.--The Commissioner of Food and Drugs shall
develop high-quality, evidence-based opioid analgesic
prescribing guidelines for the indication-specific treatment
of acute pain in the relevant therapeutic areas where such
guidelines do not exist.
(b) Public Input.--In developing the guidelines under
subsection (a), the Commissioner of Food and Drugs shall--
(1) conduct a public workshop, open to representatives of
State medical societies and medical boards, various medical
specialties including pain medicine specialty societies,
patient groups, pharmacists, universities, and others; and
(2) provide a period for the submission of comments by the
public.
(c) Report.--Not later than the date that is 2 years after
the date of enactment of this Act, the Commissioner of Food
and Drugs shall submit to the Committee on Energy and
Commerce of the House of Representatives and the Committee on
Health, Education, Labor, and Pensions of the Senate,
[[Page H5563]]
and post on the public website of the Food and Drug
Administration, a report on how the guidelines under
subsection (a) will be utilized to protect the public health.
(d) Updates.--The Commissioner of Food and Drugs shall
periodically--
(1) update the guidelines under subsection (a), informed by
public input described in subsection (b); and
(2) submit to the committees specified in subsection (c)
and post on the public website of the Food and Drug
Administration an updated report under subsection (c).
(e) Statement To Accompany Guidelines and
Recommendations.--The Commissioner of Food and Drugs shall
ensure that any opioid analgesic prescribing guidelines and
other recommendations developed under this section are
accompanied by a clear statement that such guidelines or
recommendations, as applicable--
(1) are intended to help inform clinical decisionmaking by
prescribers and patients; and
(2) should not be used by other parties, including pharmacy
benefit management companies, retail or community pharmacies,
or public and private payors, for the purposes of
restricting, limiting, delaying, or denying coverage for or
access to a prescription issued for a legitimate medical
purpose by an individual practitioner acting in the usual
course of professional practice.
(f) Definition.--In this section, the term ``evidence-
based'' means informed by a robust and systemic review of
treatment efficacy and clinical evidence.
The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Texas (Mr. Barton) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from Texas.
Mr. BARTON. Mr. Chairman, we have a great piece of legislation before
us today. Chairman Walden and Ranking Member Pallone have been great
leaders in shepherding dozens of opioid-related bills through the
Energy and Commerce Committee.
This particular bill, H.R. 6, is the crown jewel of all that
legislation. We all know what a scourge the opioid epidemic is. Since
2015, more Americans have died annually from opioid overdoses than from
the AIDS epidemic at its peak.
The amendment that is before us today is very simple. It requires the
FDA, after consultation with all the stakeholders in open meetings and
workshops, to develop some opioid prescription guidelines based on hard
evidence.
This amendment gives the FDA 2 years to develop these guidelines. It
requires the FDA to post the guidelines on their web page and to send
the guidelines to the Energy and Commerce Committee in the House and to
the Education and Workforce committee over in the Senate.
It is a bipartisan amendment. Congresswoman Annie Kuster of New
Hampshire and Congressman Mark Meadows of North Carolina have both
worked with myself and other members of the committee to develop this
amendment.
Opioids are a little bit different than some of the other drugs that
are abused and lead to addiction in that most people are exposed to
opioids the first time because of a prescription. They have some sort
of acute pain that opioids can help manage and in prescribing these
opioids the doctors are trying to help alleviate the pain. But everyone
reacts to opioids somewhat differently, and sometimes what is
acceptable in terms of the dosage for one individual is not acceptable
with another individual.
These guidelines will, again, be based on facts, be based on
evidence. They are advisory only. We are not trying to intervene in the
doctor/patient relationship. It will still be up to the doctor to
determine what is best for the patient. But at least the doctor will
have some fact-based guidelines with which to make the decision on what
level to prescribe these opioids if, in fact, opioids are necessary.
To quote the head of the FDA, Dr. Scott Gottlieb: ``Without evidence-
based dosing recommendations at the point of care to support and inform
rational prescribing, we're at serious risk of both undertreating some
patients who could benefit from opioid therapy, and overtreating a lot
of patients who are then placed at a higher risk of addiction.''
I will say that the amendment has drawn some concern, or at least
interest, from the stakeholders, the chairman, the ranking member,
myself and others are committed to working on this as it goes through
the process. If we can fine-tune the amendment in some way, we are
willing to at least consider that.
But as it is constructed today, Mr. Chairman, this is a good
amendment, and I hope that the body will adopt it.
Mr. Chairman, I reserve the balance of my time.
Mr. PALLONE. Mr. Chairman, I would like to request time to speak in
favor of the amendment.
The Acting CHAIR. Does anyone claim time in opposition?
Mr. WALDEN. I claim time in opposition, Mr. Chairman, although I am
not opposed to the amendment, and I will yield to my friend from New
Jersey in a second, but I do ask unanimous consent to claim the time in
opposition.
The Acting CHAIR. Is there objection to the request of the gentleman
from Oregon?
There was no objection.
The Acting CHAIR. The gentleman from Oregon is recognized for 5
minutes.
Mr. WALDEN. Mr. Chair, I rise in support of this amendment, and I
want to thank Representatives Barton and Meadows and Kuster. They have
really worked hard on this and it is a good amendment.
There is wide variation in the way acute, short-duration pain is
treated with opioids, and there are concerns that patients may be over-
or underprescribed opioid analgesics to treat that pain.
This amendment would direct the FDA Commissioner to develop high-
quality, evidence-based opioid prescribing guidelines for the treatment
of acute pain. By arming physicians with this type of information, we
can give them more of the tools they need to treat patients' pain
without overprescribing addictive medications.
The intent behind this policy is that evidence-based guidelines would
add to the universe of available data in a way that would empower
providers, patients, caregivers and others to make determinations about
treatment in a more informed manner.
I understand that some stakeholders have raised some concerns about
limitations on how these evidence-based guidelines can be used; so as
we continue to work on these policies with our counterparts in the
Senate, we are committed to working to ensure that the language
accomplishes what the sponsors intend without having any unintended
consequences.
I encourage my colleagues to support adoption of the amendment.
Mr. Chair, I yield to the gentleman from New Jersey (Mr. Pallone)
such time as he may consume.
Mr. PALLONE. Mr. Chairman, I rise in order to speak on the amendment
offered by Representatives Barton, Meadows and Kuster.
FDA Commissioner Gottlieb testified before the Energy and Commerce
Committee about the work the agency is doing currently to analyze and
assess opioid analgesic use in situations of acute pain, such as
following surgical procedures. The goal of this analysis is to provide
evidence-based recommendations for appropriate opioid doses by
indicators ensuring that prescribing more closely aligns with clinical
need.
I believe this is a goal that we all support, which is why I support
giving FDA the authority to conduct such work so as to inform policies
that will better protect public health, and help to reduce the unneeded
opioids from reaching individuals that are at risk for addiction.
Since this amendment has been filed, we have heard some concerns from
stakeholders about the amendment possibly impeding the use of the FDA's
evidence-based guidelines in making decisions related to dispensing or
coverage of opioid prescriptions. I believe that such decisions should
be informed by evidence-based guidelines such as those developed by the
FDA, and I hope that we can work with the amendment's sponsors and the
chairman to address these concerns moving forward.
Mr. WALDEN. Mr. Chairman, I have no further speakers on this matter.
Again, I thank my friend, the former chairman of the full committee,
Mr. Barton, for his good leadership on this effort, along with other
Members on both sides of the aisle.
I encourage our colleagues to support this amendment, and I yield
back the balance of my time.
Mr. BARTON. Mr. Chairman, can I inquire how much time I still have.
The Acting CHAIR. The gentleman from Texas has 1 minute remaining.
[[Page H5564]]
Mr. BARTON. Mr. Chairman, I yield 1 minute to the gentlewoman from
New Hampshire (Ms. Kuster), who is an original cosponsor of the
amendment and has worked very hard on it.
Ms. KUSTER of New Hampshire. Mr. Chairman, I rise in support of the
Barton amendment. This amendment would require the FDA to create high-
quality, evidence-based opioid prescribing guidelines for acute pain.
These would complement prescribing guidelines for chronic pain created
in 2015 by the Centers for Disease Control and Prevention.
Taken together, these guidelines would finally provide providers
evidence-based recommendations on best practices for all types of pain.
While the opioid epidemic has many origins, it is universally agreed
upon that the treatment of pain over the latter half of the 20th
century is a significant contributing factor. In recent years, efforts
by this Congress and the public to reconcile addiction and chronic pain
has had a real and positive impact.
One of the most impacted communities are veterans, and in just the
last few years, the VA has reported a remarkable decline in opioid
prescriptions.
Yet, the focus until very recently has been on chronic pain. Acute
pain impacts more people and is responsible for a massive share of
opioid prescriptions. The country needs evidence-based guidance on
treatment of acute pain.
FDA is armed with a trove of data on acute pain prescription rates
and patterns. They are uniquely positioned to provide this needed
guidance.
FDA Commissioner Scott Gottlieb told my colleagues on the Energy &
Commerce Committee that this is something he wants to do and he
underscored the importance of evidence-based opioid prescribing
guidelines at the 2018 National Rx Drug Abuse & Heroin Summit.
While these guidelines are focused on the prescriber practices and
patients, given the nature of pain management as team-based, we intend
these recommendations to inform better practices by providers that have
collaborative working relationships with prescribers.
I am committed to working with all stakeholders to improve this
amendment as Congress continues to consider opioid legislation to
ensure that these guidelines are considered consistent with law while
still providing effective pain care for all Americans.
Mr. BARTON. Mr. Chair, I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from Texas (Mr. Barton).
The amendment was agreed to.
Amendment No. 4 Offered by Mr. Curtis
The Acting CHAIR. It is now in order to consider amendment No. 4
printed in part B of House Report 115-766.
Mr. CURTIS. Mr. Chairman, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:
Add at the end of title III the following:
SEC. 304. REPORT ON OPIOIDS PRESCRIBING PRACTICES FOR
PREGNANT WOMEN.
(a) In General.--Not later than 180 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services, in coordination with the Centers for Disease
Control and Prevention, the National Institutes of Health,
and the Substance Abuse and Mental Health Services
Administration shall develop and submit to the Congress a
report--
(1) on opioids prescribing practices for pregnant women and
recommendations for such practices;
(2) that provides recommendations for identifying and
reducing opioids misuse during pregnancy;
(3) on prescription opioid misuse during pregnancy in urban
and rural areas;
(4) on prescription opioid use during pregnancy for the
purpose of medication-assisted treatment in urban and rural
areas;
(5) evaluating current utilization of non-opiate pain
management practices in place of prescription opioids during
pregnancy;
(6) providing guidelines encouraging the use of non-opioid
pain management practices during pregnancy when safe and
effective; and
(7) that provides recommendations for increasing public
awareness and education of opioid use disorder in pregnancy,
including available treatment resources in urban and rural
areas.
(b) No Additional Funds.--No additional funds are
authorized to be appropriated for purposes of carrying out
subsection (a).
The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Utah (Mr. Curtis) and a Member opposed each will control 5
minutes.
The Chair recognizes the gentleman from Utah.
Mr. CURTIS. Mr. Chairman, I rise today to offer an amendment to
improve research and public awareness of opioid use during pregnancy. I
introduced the POPPY Study Act earlier this year to address this issue,
and I am pleased that it is being considered here today in this form.
We all know the opioid epidemic has widespread and devastating
effects. Nearly all of us know someone who has been affected by the
crisis, and many of us have grieved through the heartbreak of losing
loved ones to addiction.
Sadly, the impact this has had on Utah has been overwhelming. In my
State, six Utahns die every week as a result of the opioid overdose,
and we rank among the highest in the Nation for drug overdose deaths.
Areas of my district have some of the highest rates of opioid
prescriptions dispensed nationwide.
Tragically, Utah also leads out in prescribing the most opioids to
pregnant women. Across the Nation, 1 in 5 women receive an opioid
prescription during pregnancy but, in Utah, that number is doubled.
Of course, opioid use during pregnancy can have dramatic consequences
for a mother and her unborn child. Neonatal abstinence syndrome
presents itself as babies go through withdrawal, constant screaming,
shaking, vomiting, and difficulty sleeping and eating.
{time} 1100
This condition often requires long and expensive hospitalization. For
Medicaid-covered babies, this syndrome costs more than $460 million in
2014 alone.
Tragically, from 2004 to 2014, the rate of infants diagnosed with
opioid withdrawal symptoms increased more than 400 percent nationwide.
Across the Nation, women have been disproportionately impacted by the
opioid epidemic, and little is known about the effect this has had on
pregnant women.
Healthcare experts, providers, and patients agree there is simply too
much we don't know about why pregnant women are being prescribed
opioids and what possible alternatives might provide better healthcare
outcomes for mothers and their unborn children.
My amendment calls for increased research on current opioid
prescribing practices during pregnancy, more data on prescription
opioid misuse during pregnancy, and evaluates and encourages nonopioid
pain management therapies that are safe and effective during pregnancy.
I am proud of the work we have done here to curb the opioid epidemic,
and I applaud the chairman, ranking member, and members of the
committee for the work they have done to fight this crisis.
Mr. Chair, I encourage my colleagues to support this vital amendment
as well as the underlying bill that will help us better serve our
suffering communities, and I reserve the balance of my time.
Mr. WALDEN. Mr. Chair, although I am not opposed to the amendment, I
ask unanimous consent to claim the time in opposition.
The Acting CHAIR. Is there objection to the request of the gentleman
from Oregon?
There was no objection.
The Acting CHAIR. The gentleman from Oregon is recognized for 5
minutes.
Mr. WALDEN. Mr. Chairman, I rise to speak in support of the amendment
and to thank my friend from Utah, Mr. Curtis, for his hard work on this
very thoughtful piece of legislation.
It is important that women who take opioid pain medications are aware
of the possible risks during pregnancy. You heard him delineate those
tragic, tragic risks, such as premature birth and neonatal abstinence
syndrome, or NAS.
While there is increasing awareness and use of nonopioid approaches
in the management of pain over all, information about their use in
pregnant patients and unique considerations of mother and child are
simply lacking.
So this amendment requires the Department of Health and Human
Services to report on the opioid prescribing practices and opioid
misuse during pregnancy, and evaluate nonopioid alternatives to pain
management during pregnancy.
[[Page H5565]]
This will complement the efforts of the Protecting Our Infants Act,
which required a report on prenatal opioid exposure and NAS, presenting
a strategy and clinical recommendations for preventing and treating
infants withdrawal.
I encourage my colleagues to support this amendment.
Mr. Chair, I yield such time as he may consume to the gentleman from
Louisiana (Mr. Scalise), a very important Member not only of the U.S.
House of Representatives as our whip, but a very influential and
effective member on our Energy and Commerce Committee.
Mr. SCALISE. Mr. Chairman, I thank the chairman for yielding me the
time and for leading on this important issue.
Mr. Chairman, I rise in strong support of my friend from Utah's
amendment. As he mentioned, Mr. Chairman, you look at this crisis in
our country, and I am so glad that Congress is taking a wide array of
actions to address the opioid crisis in our country, because it doesn't
affect just one community or another. Everybody might think ``mine is
the only problem,'' and then you talk to other Members of Congress from
around the country, and you find out they are experiencing the same
kind of crisis. And it is widespread. It is killing people every single
day.
But as we are talking about on this amendment, Mr. Chairman, we are
talking about children, children that are born to a mother that is
addicted to opioids.
I highlight Kemper, a young boy from my district in Slidell,
Louisiana. He was born addicted to opioids because his mother, while
she was pregnant, was addicted to opioids herself.
Now, I wish that this was the only time that it had happened.
Fortunately for all of us, Kemper is now a healthy young boy, but he
spent his first 11 days of life in the hospital fighting to beat a drug
addiction that was not created, of course, on his own.
We would like to think that this might be an isolated example, but,
Mr. Chairman, this example highlights something the Centers for Disease
Control has noted, and that is, once every 25 minutes in America, a
baby is born addicted to opioids--one every 25 minutes. That is how
widespread it is just for babies that are born.
When we talk about this entire package of bills, today, H.R. 6 is
going to pull together 50 different bills covering many different parts
of this problem. It is an incredibly bipartisan effort. I know, Mr.
Chairman, so often we hear about the partisan wrangling in Congress.
Clearly, there are divided lines on some high-profile issues, but this
is an issue where Republicans and Democrats have come together.
I want to thank my friends from both sides of the aisle for
recognizing this problem and coming together in a bipartisan way to
solve it.
This is going to give real tools to our communities so that they can
combat this at every different level we are seeing, including
treatment, including law enforcement to stop these deadly drugs from
getting on the streets so that more babies like Kemper are not born
addicted to opioids.
Mr. Chairman, I encourage all my colleagues to support this amendment
and the underlying package of bills.
Mr. WALDEN. Mr. Chairman, I urge passage, and I yield back the
balance of my time.
Mr. CURTIS. Mr. Chairman, I thank the gentleman from Louisiana and
the chairman for their speaking out in support of this important bill.
Mr. Chairman, this amendment is essential in helping us improve our
understanding of the impact of using opioid prescription during
pregnancy and, ultimately, preventing opioid use disorder entirely. It
is vital that we have sound and accurate research to guide us in the
best ways to help pregnant women suffering from addiction.
Mr. Chairman, this is a critical amendment. I urge my colleagues to
support it, and I yield back the balance of my time.
The Acting CHAIR (Mr. Weber of Texas). The question is on the
amendment offered by the gentleman from Utah (Mr. Curtis).
The amendment was agreed to.
Amendment No. 5 Offered by Mr. Keating
The Acting CHAIR. It is now in order to consider amendment No. 5
printed in part B of House Report 115-766.
Mr. KEATING. Mr. Chair, I have an amendment at the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:
Add at the end of title III the following:
SEC. 304. GUIDELINES FOR PRESCRIBING NALOXONE.
(a) In General.--Not later than 180 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall issue guidelines for prescribing an opioid
overdose reversal drug.
(b) Contents.--In issuing guidelines under subsection (a),
the Secretary shall address the following:
(1) Co-prescribing an opioid overdose reversal drug in
conjunction with any prescribed opioid.
(2) Dosage safety.
(3) Prescribing an opioid overdose reversal drug to an
individual other than a patient.
(4) Standing orders.
(5) Other distribution, education, and safety measures as
determined necessary.
The Acting CHAIR. Pursuant to House Resolution 949, the gentleman
from Massachusetts (Mr. Keating) and a Member opposed each will control
5 minutes.
The Chair recognizes the gentleman from Massachusetts.
Mr. KEATING. Mr. Chairman, I rise in support of my amendment that
directs the Department of the Health and Human Services to issue and
expand guidelines for medical providers for prescribing naloxone to
reflect a major shift that has occurred in the opioid health crisis
that we continue to work to counter today.
Mr. Chairman, earlier this year, I sat in a room with my colleagues
on the Bipartisan Heroin Task Force and listened to Dr. Francis Collins
and the NIH leadership present data revealing how we have seen a shift
in the opioid crisis.
For the first time, we learned that opioid overdoses from
prescriptions of opioid drugs have dropped. That is good news.
The shocking news was that overdose rates for illicit opioids, heroin
and fentanyl, had risen at an alarming rate.
If we are going to save lives of people overdosing from increasingly
prevalent and increasingly unpredictable illicit compounds, we need to
make sure naloxone gets in the right hands.
My amendment would provide necessary guidance to patients, providers,
public health professionals, first responders, and loved ones on the
ability to obtain effective doses of naloxone to combat overdoses of
all types of opioids, prescriptions or otherwise.
It is so crucial that people dealing with this brain disease know how
to use naloxone in an emergency and, importantly, understand that it is
okay to have naloxone in the home.
I was proud that I and the gentleman from Pennsylvania (Mr. Rothfus),
who also joins me as a cosponsor of this bipartisan amendment, were
able to insert legislative language on prescribing guidelines into the
Comprehensive Addiction and Recovery Act that passed Congress and
became law last year. But giving HHS the option to issue guidelines
didn't go far enough.
This amendment before us is firm in its requirement, and I believe my
amendment will more explicitly and more expansively direct and yield
necessary change.
Mr. Chairman, I conclude by reaffirming our commitment to ending this
devastating epidemic that takes the lives of 115 people every day on
average in our country.
I share this commitment with the Members of the House, and I pledge
to work with you all to see this amendment's passage and to effect
necessary change that reflects the ever-shifting landscape in this
battle.
Mr. Chairman, I yield 2 minutes to the gentleman from Pennsylvania
(Mr. Rothfus), the cosponsor of this amendment.
Mr. ROTHFUS. Mr. Chairman, I thank the gentleman for yielding time to
me.
Mr. Chairman, I rise to urge my colleagues to support this amendment
to H.R. 6, and I want to thank my colleague, the gentleman from
Massachusetts (Mr. Keating), for his work on this effort. We have
worked before on this issue of naloxone, and it is great that he is
bringing forth this amendment. I am happy to be cosponsoring it with
him.
The House has been doing amazing, wide-ranging work over the last 2
weeks to combat the opioid crisis, and
[[Page H5566]]
I am proud to have assisted with these efforts.
The amendment that I have cojoined with Congressman Keating today is
simple. It instructs the Secretary of Health and Human Services to give
additional guidance to prescribing naloxone.
Naloxone is the drug used to reverse opioid overdoses, a situation
that far too many Americans have found themselves in across the country
and across western Pennsylvania.
Opioid addiction is tearing families apart. Unfortunately, an
overdose is frequently the grim end to a long struggle.
If we can help some of our fellow Americans come back from the brink
with increased knowledge for our Nation's medical professionals, I see
no reason not to do it.
Mr. Chairman, I urge my colleagues to support this amendment. I again
thank Congressman Keating for his leadership on this.
Mr. WALDEN. Mr. Chairman, although I am not opposed to the amendment,
I ask unanimous consent to claim time in opposition.
The Acting CHAIR. Is there objection to the request of the gentleman
from Oregon?
There was no objection.
The Acting CHAIR. The gentleman from Oregon is recognized for 5
minutes.
Mr. WALDEN. Mr. Chairman, I rise to speak in support of the amendment
that requires the Department of Health and Human Services to issue
guidelines for prescribing an opioid overdose reversal drug.
The guidelines would cover dosage safety, standing orders and other
education, and distribution measures.
In April, the Surgeon General issued an advisory calling for more
people to carry naloxone.
Expanding the use of this lifesaving drug is a key part of the public
health response to the opioid crisis, along with effective prevention,
treatment, and recovery programs for substance use disorder.
I can just tell you, Mr. Chairman, from my own district, I have had
multiple roundtables in every corner of the district. I have, of
course, met with families that have been affected. I have met with
addiction treatment specialists. I have met with medical providers. But
I have also met with law enforcement.
In Oregon, we lead in a lot of this recovery effort, but also in
making sure naloxone is available. This is the antidote.
Mr. Chair, these fentanyls that are coming into our country
illegally, if I had a little salt shaker here and put out, I don't
know, a half a dozen, a dozen grains of salt, and you put your hand on
it, you would likely absorb that through your skin and pass out. And
if somebody in this Chamber didn't have naloxone, or the medical people
who are nearby didn't get to you in time, you would be one of those 115
people who will die in the next 24 hours, or one of the thousand that
will show up in our emergency rooms.
So moving forward with guidelines for prescribing an opioid overdose
reversal drug really makes sense. Moving forward with naloxone really
makes sense.
We will save lives with this amendment, and I commend my colleagues
from Massachusetts and Pennsylvania for their good work on this. We are
happy to accept it as part of H.R. 6, and I yield back the balance of
my time.
Mr. KEATING. Mr. Chairman, in Cape Cod, the islands, and South Shore
and south coast of Massachusetts, the real cause of death in overdoses
now is fentanyl. It is being mixed with cocaine. It is being mixed with
marijuana. And this is very important.
This bipartisan amendment will save lives. I want to thank Chairman
Walden. I want to thank Chairman Brady. I want to thank my cosponsor
Mr. Rothfus. I want to thank Ranking Member Pallone and Ranking Member
Neal for their work on an amendment that will truly save lives.
Mr. WALDEN. Will the gentleman yield?
Mr. KEATING. Mr. Chairman, I yield to the gentleman from Oregon.
Mr. WALDEN. Mr. Chairman, because the gentleman raised the issue of
these synthetics on other--we have talked a lot about fentanyl being
cut into heroin over the course of this debate over 2 weeks.
We haven't talked as much about these synthetics being sprayed on
marijuana or other things that you go: Oh, that is natural, mom. I can
smoke that.
And what these evil people are doing is taking these deadly
synthetics and literally creating a liquid or a spray and then spraying
it.
And I talked to a father the other day whose daughter died of a
heroin overdose, but when they did the autopsy, they discovered it was
100 percent fentanyl. So I thank the gentleman for his good work on
this amendment.
Mr. KEATING. Mr. Chairman, I yield back the balance of my time.
The Acting CHAIR. The question is on the amendment offered by the
gentleman from Massachusetts (Mr. Keating).
The amendment was agreed to.
The Acting CHAIR. It is now in order to consider amendment No. 6
printed in part B of House Report 115-766.
Amendment No. 7 Offered by Ms. Maxine Waters of California
The Acting CHAIR. It is now in order to consider amendment No. 7
printed in part B of House Report 115-766.
Ms. MAXINE WATERS of California. Mr. Chairman, I have an amendment at
the desk.
The Acting CHAIR. The Clerk will designate the amendment.
The text of the amendment is as follows:
Add at the end of title III the following new section:
SEC. ___. REQUIRING A SURVEY OF SUBSTANCE USE DISORDER
TREATMENT PROVIDERS RECEIVING FEDERAL FUNDING.
(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a survey of all entities that receive Federal funding
for the purpose of providing substance use disorder treatment
services. The survey shall direct such entities to provide
the following information:
(1) The length of time the entity has provided substance
use disorder treatment services.
(2) A detailed description of the patient population served
by the entity, including but not limited to the number of
patients, type of addictions, geographic area served, as well
as gender, racial, ethnic and socioeconomic demographics of
such patients.
(3) A detailed description of the types of addiction for
which the entity has the experience, capability, and capacity
to provide such services.
(4) An explanation of how the entity handles patients
requiring treatment for a substance use disorder that the
organization is not able to treat.
(5) A description of what is needed, in the opinion of the
entity, in order to improve the entity's ability to meet the
addiction treatment needs of the communities served by that
entity.
(6) Based on the identified needs of the communities
served, a description of unmet needs and inadequate services
and how such needs and services could be better addressed
through additional Federal, State, or local government
resources or funding to treat addiction to methamphetamine,
crack cocaine, other types of cocaine, heroin, opioids, and
other commonly abused drugs.
(b) Report.--Not later than 1 year after the date of the
enactment of this Act, the Secretary shall develop and submit
to Congress a plan to direct appropriate resources to
entities that provide substance use disorder treatment
services in order to address inadequacies in services or
funding identified through the survey described in subsection
(a).
The Acting CHAIR. Pursuant to House Resolution 949, the gentlewoman
from California (Ms. Maxine Waters) and a Member opposed each will
control 5 minutes.
The Chair recognizes the gentlewoman from California.
{time} 1115
Ms. MAXINE WATERS of California. Mr. Chairman, first I would like to
say that I appreciate the bipartisan work of the bill's sponsor,
Chairman Greg Walden, and, of course, Chairman Kevin Brady and our
cosponsor Frank Pallone and cosponsor Richard Neal on this bill, H.R.
6, the SUPPORT for Patients and Communities Act.
=========================== NOTE ===========================
June 22, 2018, on page H5566, the following appeared: Ms. MAXINE
WATERS of California. Mr. Chairman, first I would like to say that
I appreciate the bipartisan work of the bill's sponsor, Chairman
GREG WALDEN, and, of course, Chairman Ken Brady and our cosponsor
FRANK PALLONE and cosponsor RICHARD NEAL on this bill, H.R. 6, the
SUPPORT for Patients and Communities Act.
The online version has been corrected to read: Ms. MAXINE WATERS
of California. Mr. Chairman, first I would like to say that I
appreciate the bipartisan work of the bill's sponsor, Chairman
GREG WALDEN, and, of course, Chairman KEVIN BRADY and our
cosponsor FRANK PALLONE and cosponsor RICHARD NEAL on this bill,
H.R. 6, the SUPPORT for Patients and Communities Act.
========================= END NOTE =========================
The bill, as drafted, includes many positive provisions and extends
well-intended legislative efforts to address the opioid crisis in this
country. That said, as we all know, in the United States, people suffer
from a wide range of substance use disorders, including alcoholism and
the abuse of illegal drugs like heroin, methamphetamine, crack, and
other forms of cocaine. Likewise, there are a range of entities that
provide different types of substance abuse treatment services.
[[Page H5567]]
The purpose of my amendment is to ensure that we have a clear
understanding of the substance abuse treatment services available, the
communities and the populations that are being served, the types of
substance use disorders being addressed, and any other unmet needs or
inadequacies in the way we are addressing substance abuse issues.
My amendment would direct that the Department of Health and Human
Services conduct a nationwide survey of entities that provide substance
use disorder treatment services. Based on the results of that survey,
my amendment directs HHS to develop and submit to Congress a plan to
direct appropriate resources in order to address inadequacies in
services or funding identified through the survey.
The survey called for by my amendment is intended to complement
existing efforts by the Substance Abuse and Mental Health Services
Administration, SAMHSA, to examine substance use treatment services in
order to develop a concrete plan to address unmet needs.
Mr. Chairman, let me just say that I appreciate the information that
was shared by the majority whip, Mr. Scalise, when he talked about the
baby who was born addicted, and we are going to have a lot of that.
I have one regret, having worked on the issue of crack cocaine, that
we did not do something to do the research that was necessary on these
babies that are born addicted, to find out what happens to them later
on in life and whether or not these children are handicapped and
disabled in some ways, have learning disabilities, and on and on and
on. So I would like to work with Mr. Scalise to do the follow-up for
the research that is so necessary.
Mr. Chair, I reserve the balance of my time.
Mr. WALDEN. Mr. Chairman, although I am not opposed to the amendment,
I ask unanimous consent to claim the time in opposition.
The Acting CHAIR. Is there objection to the request of the gentleman
from Oregon?
There was no objection.
The Acting CHAIR. The gentleman from Oregon is recognized for 5
minutes.
Mr. WALDEN. Mr. Chair, I rise to speak in support of this amendment
and to thank my friend, Ms. Waters, for her work on this initiative.
Before I go through that, I just want to say we are more than happy
to team up with the gentlewoman on this issue of crack cocaine and its
effects, and I am sure that Mr. Scalise, although I can't officially
speak for him, I am sure that he would work in partnership with the
gentlewoman.
The gentlewoman has raised an issue that we have dealt with in other
parts of this legislation but not in the part that the gentlewoman has
brought to us. There will be more going forward, I assure you, and we
would be happy to work with the gentlewoman on that.
Mr. Rush brought an amendment on the IMD issue to make sure that
those suffering from cocaine and crack cocaine addiction also could get
treatment under expansion in the IMD, so we would be happy to work with
the gentlewoman on that.
This amendment directs the Secretary of Health and Human Services to
conduct a survey of organizations that provide substance abuse
treatment services and then develop a plan to direct resources to
address any identified gaps in services for specific types of substance
use disorders. This information will help us better understand how our
Federal dollars are invested in interdiction treatment at the local
level and what more can be done with Federal resources to yield even
better returns in reducing drug-related crimes, accidents, overdoses,
and deaths.
So I certainly appreciate the gentlewoman's work on this effort. It
is important work that will help save lives and bring about the kind of
treatment we need in our communities.
I encourage adoption of the amendment, and I yield back the balance
of my time.
Ms. MAXINE WATERS of California. Mr. Chairman, I yield back the
balance of my time
The Acting CHAIR. The question is on the amendment offered by the
gentlewoman from California (Ms. Maxine Waters).
The amendment was agreed to.
The Acting CHAIR (Mrs. Walorski). The Chair understands that
amendment No. 8 will not be offered.
There being no further amendments, under the rule, the Committee
rises.
Accordingly, the Committee rose; and the Speaker pro tempore (Mr.
Weber of Texas) having assumed the chair, Mrs. Walorski, Acting Chair
of the Committee of the Whole House on the state of the Union, reported
that that Committee, having had under consideration the bill (H.R. 6)
to provide for opioid use disorder prevention, recovery, and treatment,
and for other purposes, and, pursuant to House Resolution 949, she
reported the bill, as amended by that resolution, back to the House
with sundry further amendments adopted in the Committee of the Whole.
The SPEAKER pro tempore. Under the rule, the previous question is
ordered.
Is a separate vote demanded on any further amendment reported from
the Committee of the Whole? If not, the Chair will put them en gros.
The amendments were agreed to.
The SPEAKER pro tempore. The question is on the engrossment and third
reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.
Motion to Recommit
Mr. TONKO. Mr. Speaker, I have a motion to recommit at the desk.
The SPEAKER pro tempore. Is the gentleman opposed to the bill?
Mr. TONKO. I am opposed in its current form.
The SPEAKER pro tempore. The Clerk will report the motion to
recommit.
The Clerk read as follows:
Mr. Tonko moves to recommit the bill H.R. 6 to the
Committee on Energy and Commerce and the Committee on Ways
and Means with instructions to report the same back to the
House forthwith with the following amendment:
Page 84, after line 14, insert the following:
SEC. 208. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS TO
HELP COMBAT OPIOID CRISIS.
(a) In General.--Section 1886(h) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraphs (7)
and (8)'' and inserting ``paragraphs (7), (8), and (9)'';
(2) in paragraph (4)(H)(i), by striking ``paragraphs (7)
and (8)'' and inserting ``paragraphs (7), (8), and (9)'';
(3) in paragraph (7)(E), by inserting ``paragraph (9),''
after ``paragraph (8),''; and
(4) by adding at the end the following new paragraph:
``(9) Distribution of additional residency positions to
help combat opioid crisis.--
``(A) Additional residency positions.--For each of fiscal
years 2021 through 2025 (and succeeding fiscal years if the
Secretary determines that there are additional residency
positions available to distribute under subparagraph (D)),
the Secretary shall increase the otherwise applicable
resident limit for each qualifying hospital that submits a
timely application under this subparagraph by such number as
the Secretary may approve for portions of cost reporting
periods occurring on or after July 1 of the fiscal year of
the increase. Except as provided in subparagraph (B)(iv) or
(D), the aggregate number of increases in the otherwise
applicable resident limit under this subparagraph shall be
equal to 500 over the period of fiscal years 2021 through
2025, distributed in accordance with the succeeding
subparagraphs of this paragraph.
``(B) Distribution for fiscal year 2021.--
``(i) In general.--For fiscal year 2021, the positions
available for distribution with respect to the fiscal year as
described in subparagraph (A) shall be distributed to
hospitals that have existing established approved programs in
addiction medicine, addiction psychiatry, or pain medicine as
determined by the Secretary. The Secretary shall establish
standards and a process for ensuring additional residency
positions under this subparagraph are used to increase the
number of residents studying in the fields specified in the
previous sentence.
``(ii) Number of positions hospital eligible to receive.--
Subject to clauses (iii) and (iv), the aggregate number of
positions a hospital may receive under this subparagraph with
respect to fiscal year 2021 is equal to the sum of the
following:
``(I) The number of full-time-equivalent residents that
will be training in addiction medicine, addiction psychiatry,
or pain medicine as determined by the Secretary with respect
to the fiscal year.
``(II) The associated number, as defined by the Secretary,
of residents training in a pre-requisite program, such as
internal medicine, necessary for the number of full-time
residents for the programs described in subclause (I).
``(iii) Additional positions for expansion of existing
program.--If a hospital demonstrates to the Secretary that
the hospital is planning to increase the number of full-
[[Page H5568]]
time-equivalent residents in existing programs described in
clause (i), the Secretary may increase the number of
positions a hospital is eligible to receive under clause (ii)
in order to accommodate that expansion, as determined by the
Secretary.
``(iv) Considerations in distribution.--The Secretary shall
distribute additional residency positions under this
subparagraph based on--
``(I) in the case of positions made available under clause
(ii), the demonstrated likelihood, as defined by the
Secretary, of the hospital filling such positions by July 1,
2021; and
``(II) in the case of positions made available under clause
(iii), the demonstrated likelihood, as so defined, of the
hospital filling such positions within the first three cost
reporting periods beginning on or after July 1, 2021.
``(v) Limitation.--Notwithstanding clauses (ii) and (iv),
an individual hospital may not receive more than 25 full-
time-equivalent residency positions under this paragraph.
``(vi) Positions not distributed during the fiscal year.--
If the number of resident full-time-equivalent positions
distributed under this subparagraph is less than the
aggregate number of positions available for distribution in
the fiscal year (as described in subparagraph (A)), the
difference between such number distributed and such number
available for distribution shall be added to the aggregate
number of positions available for distribution under
subparagraph (C).
``(C) Distribution for fiscal years 2022 through 2025.--
``(i) In general.--For the period of fiscal years 2022
through 2025, the positions available for distribution with
respect to such period (as described in subparagraph (A),
including after application of subparagraph (B)(vi)) shall be
distributed to hospitals which demonstrate to the Secretary
that the hospital--
``(I) will establish an approved program in addiction
medicine, addiction psychiatry, or pain medicine; and
``(II) will use all of the additional positions made
available under this subparagraph in such program or a
prerequisite residency program for such program within the
first four cost reporting periods after the increase would be
effective.
``(ii) Requirements.--Subject to clause (iii), a hospital
that receives an increase in the otherwise applicable
resident limit under this subparagraph shall ensure, during
the 10-year period beginning after the date of such increase,
that the hospital uses the positions received under clauses
(i)(I) and (i)(II) for the programs for which the positions
were distributed, or similar programs (as determined by the
Secretary). The Secretary may determine whether a hospital
has met the requirements under this clause during such 10-
year period in such manner and at such time as the Secretary
determines appropriate, including at the end of such 10-year
period.
``(iii) Redistribution of positions if hospital no longer
meets certain requirements.--In the case where the Secretary
determines that a hospital described in clause (ii) does not
meet the requirements of such clause, the Secretary shall--
``(I) reduce the otherwise applicable resident limit of the
hospital by the amount by which such limit was increased
under this subparagraph; and
``(II) provide for the distribution of positions
attributable to such reduction in accordance with the
requirements of this paragraph.
``(D) Distribution of remaining positions.--If the
aggregate number of positions distributed under subparagraphs
(B) and (C) during the period of fiscal years 2021 through
2025 is less than 500, the Secretary shall distribute the
remaining residency positions in succeeding fiscal years
according to criteria consistent with this paragraph until
such time as the aggregate amount of positions distributed
under this paragraph is equal to 500.
``(E) Notification.--The Secretary shall notify hospitals
of the number of positions distributed to the hospital under
this paragraph as a result on an increase in the otherwise
applicable resident limit by January 1 of the fiscal year of
the increase. Such increase shall be effective for portions
of cost reporting periods beginning on or after July 1 of
that fiscal year.
``(F) Application of per resident amounts for primary care
and nonprimary care.--With respect to additional residency
positions in a hospital attributable to the increase provided
under this paragraph, the approved FTE per resident amounts
are deemed to be equal to the hospital per resident amounts
for primary care and nonprimary care computed under paragraph
(2)(D) for that hospital.
``(G) Permitting facilities to apply aggregation rules.--
The Secretary shall permit hospitals receiving additional
residency positions attributable to the increase provided
under this paragraph to, beginning in the fifth year after
the effective date of such increase, apply such positions to
the limitation amount under paragraph (4)(F) that may be
aggregated pursuant to paragraph (4)(H) among members of the
same affiliated group.
``(H) Definitions.--In this paragraph:
``(i) Otherwise applicable resident limit.--The term
`otherwise applicable resident limit' means, with respect to
a hospital, the limit otherwise applicable under
subparagraphs (F)(i) and (H) of paragraph (4) on the resident
level for the hospital determined without regard to this
paragraph but taking into account paragraphs (7)(A), (7)(B),
(8)(A), and (8)(B).
``(ii) Resident level.--The term `resident level' has the
meaning given such term in paragraph (7)(C)(i).''.
(b) IME.--
(1) In general.--Section 1886(d)(5)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the third
sentence, is amended by striking ``and (h)(8)'' and inserting
``(h)(8), and (h)(9)''.
(2) Conforming provision.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended--
(A) by redesignating clause (x), as added by section
5505(b) of the Patient Protection and Affordable Care Act
(Public Law 111-148), as clause (xi) and moving such clause 4
ems to the left; and
(B) by adding after clause (xi), as redesignated by
subparagraph (A), the following new clause:
``(xii) For discharges occurring on or after July 1, 2021,
insofar as an additional payment amount under this
subparagraph is attributable to resident positions
distributed to a hospital under subsection (h)(9), the
indirect teaching adjustment factor shall be computed in the
same manner as provided under clause (ii) with respect to
such resident positions.''.
Page 95, after line 21, insert the following:
SEC. 304. ACTIONS FOR DELAYS OF GENERIC DRUGS AND BIOSIMILAR
BIOLOGICAL PRODUCTS.
(a) Definitions.--In this section--
(1) the term ``commercially reasonable, market-based
terms'' means--
(A) a non-discriminatory price for the sale of the covered
product at or below, but not greater than, the most recent
wholesale acquisition cost for the drug, as defined in
section 1847A(c)(6)(B) of the Social Security Act (42 U.S.C.
1395w-3a(c)(6)(B));
(B) a schedule for delivery that results in the transfer of
the covered product to the eligible product developer
consistent with the timing under subsection (b)(2)(A)(iv);
and
(C) no additional conditions are imposed on the sale of the
covered product;
(2) the term ``covered product''--
(A) means--
(i) any drug approved under subsection (b) or (j) of
section 505 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355) or biological product licensed under subsection
(a) or (k) of section 351 of the Public Health Service Act
(42 U.S.C. 262);
(ii) any combination of a drug or biological product
described in clause (i); or
(iii) when reasonably necessary to support approval of an
application under section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355), or section 351 of the Public
Health Service Act (42 U.S.C. 262), as applicable, or
otherwise meet the requirements for approval under either
such section, any product, including any device, that is
marketed or intended for use with such a drug or biological
product; and
(B) does not include any drug or biological product that
the Secretary has determined to be currently in shortage and
that appears on the drug shortage list in effect under
section 506E of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356e), unless the shortage will not be promptly
resolved--
(i) as demonstrated by the fact that the drug or biological
product has been in shortage for more than 6 months; or
(ii) as otherwise determined by the Secretary;
(3) the term ``device'' has the meaning given the term in
section 201 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 321);
(4) the term ``eligible product developer'' means a person
that seeks to develop a product for approval pursuant to an
application for approval under subsection (b)(2) or (j) of
section 505 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355) or for licensing pursuant to an application under
section 351(k) of the Public Health Service Act (42 U.S.C.
262(k));
(5) the term ``license holder'' means the holder of an
application approved under subsection (c) or (j) of section
505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
355) or the holder of a license under subsection (a) or (k)
of section 351 of the Public Health Service Act (42 U.S.C.
262) for a covered product;
(6) the term ``REMS'' means a risk evaluation and
mitigation strategy under section 505-1 of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355-1);
(7) the term ``REMS with ETASU'' means a REMS that contains
elements to assure safe use under section 505-1 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355-1);
(8) the term ``Secretary'' means the Secretary of Health
and Human Services;
(9) the term ``single, shared system of elements to assure
safe use'' means a single, shared system of elements to
assure safe use under section 505-1 of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355-1); and
(10) the term ``sufficient quantities'' means an amount of
a covered product that allows the eligible product developer
to--
(A) conduct testing to support an application--
(i) for approval under subsection (b)(2) or (j) of section
505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
355); or
(ii) for licensing under section 351(k) of the Public
Health Service Act (42 U.S.C. 262(k)); and
[[Page H5569]]
(B) fulfill any regulatory requirements relating to such an
application for approval or licensing.
(b) Civil Action for Failure to Provide Sufficient
Quantities of a Covered Product.--
(1) In general.--An eligible product developer may bring a
civil action against the license holder for a covered product
seeking relief under this subsection in an appropriate
district court of the United States alleging that the license
holder has declined to provide sufficient quantities of the
covered product to the eligible product developer on
commercially reasonable, market-based terms.
(2) Elements.--
(A) In general.--To prevail in a civil action brought under
paragraph (1), an eligible product developer shall prove, by
a preponderance of the evidence--
(i) that--
(I) the covered product is not subject to a REMS with
ETASU; or
(II) if the covered product is subject to a REMS with
ETASU--
(aa) the eligible product developer has obtained a covered
product authorization from the Secretary in accordance with
subparagraph (B); and
(bb) the eligible product developer has provided a copy of
the covered product authorization to the license holder;
(ii) that, as of the date on which the civil action is
filed, the product developer has not obtained sufficient
quantities of the covered product on commercially reasonable,
market-based terms;
(iii) that the eligible product developer has requested to
purchase sufficient quantities of the covered product from
the license holder; and
(iv) that the license holder has not delivered to the
eligible product developer sufficient quantities of the
covered product on commercially reasonable, market-based
terms--
(I) for a covered product that is not subject to a REMS
with ETASU, by the date that is 31 days after the date on
which the license holder received the request for the covered
product; and
(II) for a covered product that is subject to a REMS with
ETASU, by 31 days after the later of--
(aa) the date on which the license holder received the
request for the covered product; or
(bb) the date on which the license holder received a copy
of the covered product authorization issued by the Secretary
in accordance with subparagraph (B).
(B) Authorization for covered product subject to a rems
with etasu.--
(i) Request.--An eligible product developer may submit to
the Secretary a written request for the eligible product
developer to be authorized to obtain sufficient quantities of
an individual covered product subject to a REMS with ETASU.
(ii) Authorization.--Not later than 120 days after the date
on which a request under clause (i) is received, the
Secretary shall, by written notice, authorize the eligible
product developer to obtain sufficient quantities of an
individual covered product subject to a REMS with ETASU for
purposes of--
(I) development and testing that does not involve human
clinical trials, if the eligible product developer has agreed
to comply with any conditions the Secretary determines
necessary; or
(II) development and testing that involves human clinical
trials, if the eligible product developer has--
(aa)(AA) submitted protocols, informed consent documents,
and informational materials for testing that include
protections that provide safety protections comparable to
those provided by the REMS for the covered product; or
(BB) otherwise satisfied the Secretary that such
protections will be provided; and
(bb) met any other requirements the Secretary may
establish.
(iii) Notice.--A covered product authorization issued under
this subparagraph shall state that the provision of the
covered product by the license holder under the terms of the
authorization will not be a violation of the REMS for the
covered product.
(3) Affirmative defense.--In a civil action brought under
paragraph (1), it shall be an affirmative defense, on which
the defendant has the burden of persuasion by a preponderance
of the evidence--
(A) that, on the date on which the eligible product
developer requested to purchase sufficient quantities of the
covered product from the license holder--
(i) neither the license holder nor any of its agents,
wholesalers, or distributors was engaged in the manufacturing
or commercial marketing of the covered product; and
(ii) neither the license holder nor any of its agents,
wholesalers, or distributors otherwise had access to
inventory of the covered product to supply to the eligible
product developer on commercially reasonable, market-based
terms; or
(B) that--
(i) the license holder sells the covered product through
agents, distributors, or wholesalers;
(ii) the license holder has placed no restrictions,
explicit or implicit, on its agents, distributors, or
wholesalers to sell covered products to eligible product
developers; and
(iii) the covered product can be purchased by the eligible
product developer in sufficient quantities on commercially
reasonable, market-based terms from the agents, distributors,
or wholesalers of the license holder.
(4) Remedies.--
(A) In general.--If an eligible product developer prevails
in a civil action brought under paragraph (1), the court
shall--
(i) order the license holder to provide to the eligible
product developer without delay sufficient quantities of the
covered product on commercially reasonable, market-based
terms;
(ii) award to the eligible product developer reasonable
attorney fees and costs of the civil action; and
(iii) award to the eligible product developer a monetary
amount sufficient to deter the license holder from failing to
provide other eligible product developers with sufficient
quantities of a covered product on commercially reasonable,
market-based terms, if the court finds, by a preponderance of
the evidence--
(I) that the license holder delayed providing sufficient
quantities of the covered product to the eligible product
developer without a legitimate business justification; or
(II) that the license holder failed to comply with an order
issued under clause (i).
(B) Maximum monetary amount.--A monetary amount awarded
under subparagraph (A)(iii) shall not be greater than the
revenue that the license holder earned on the covered product
during the period--
(i) beginning on--
(I) for a covered product that is not subject to a REMS
with ETASU, the date that is 31 days after the date on which
the license holder received the request; or
(II) for a covered product that is subject to a REMS with
ETASU, the date that is 31 days after the later of--
(aa) the date on which the license holder received the
request; or
(bb) the date on which the license holder received a copy
of the covered product authorization issued by the Secretary
in accordance with paragraph (2)(B); and
(ii) ending on the date on which the eligible product
developer received sufficient quantities of the covered
product.
(C) Avoidance of delay.--The court may issue an order under
subparagraph (A)(i) before conducting further proceedings
that may be necessary to determine whether the eligible
product developer is entitled to an award under clause (ii)
or (iii) of subparagraph (A), or the amount of any such
award.
(c) Limitation of Liability.--A license holder for a
covered product shall not be liable for any claim under
Federal, State, or local law arising out of the failure of an
eligible product developer to follow adequate safeguards to
assure safe use of the covered product during development or
testing activities described in this section, including
transportation, handling, use, or disposal of the covered
product by the eligible product developer.
(d) No Violation of REMS.--The provision of samples of a
drug pursuant to an authorization under subsection (b)(2)(B)
shall not be considered a violation of the requirements of
any risk evaluation and mitigation strategy that may be in
place under section 505-1 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355-1) for such drug.
(e) Rule of Construction.--
(1) Definition.--In this subsection, the term ``antitrust
laws''--
(A) has the meaning given the term in subsection (a) of the
first section of the Clayton Act (15 U.S.C. 12); and
(B) includes section 5 of the Federal Trade Commission Act
(15 U.S.C. 45) to the extent that such section applies to
unfair methods of competition.
(2) Antitrust laws.--Nothing in this section shall be
construed to limit the operation of any provision of the
antitrust laws.
SEC. 305. REMS APPROVAL PROCESS FOR SUBSEQUENT FILERS.
Section 505-1 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355-1) is amended--
(1) in subsection (g)(4)(B)--
(A) in clause (i) by striking ``or'' after the semicolon;
(B) in clause (ii) by striking the period at the end and
inserting ``; or''; and
(C) by adding at the end the following:
``(iii) accommodate different, comparable approved risk
evaluation and mitigation strategies for a drug that is the
subject of an abbreviated new drug application, and its
reference drug product.'';
(2) in subsection (i)(1), by striking subparagraph (B) and
inserting the following:
``(B) Elements to assure safe use, if required under
subsection (f) for the listed drug.
``(i) Subject to clause (ii), a drug that is the subject of
an abbreviated new drug application may use--
``(I) a single, shared system with the listed drug under
subsection (f); or
``(II) a different, comparable aspect of the elements to
assure safe use under subsection (f).
``(ii) The Secretary may require a drug that is the subject
of an abbreviated new drug application and the listed drug to
use a single, shared system under subsection (f), if the
Secretary determines that no different, comparable aspect of
the elements to assure safe use could satisfy the
requirements of subsection (f).''; and
(3) by adding at the end the following:
``(l) Separate REMS.--When used in this section, the terms
``different, comparable aspect of the elements to assure safe
use'' or ``different, comparable approved risk evaluation and
mitigation strategies'' means a risk
[[Page H5570]]
evaluation and mitigation strategy for a drug that is the
subject of an application under section 505(j) that uses
different methods or operational means than the strategy
required under subsection (a) for the applicable reference
drug, or other application under section 505(j) with the same
such reference listed drug, but achieves the same level of
safety as such strategy.''.
SEC. 306. FUNDING FOR OPIOID GRANT PROGRAM FOR STATE RESPONSE
TO OPIOID ABUSE CRISIS.
Section 1003(c) of the 21st Century Cures Act (42 U.S.C.
290ee-3 note) is amended by adding at the end the following
new paragraph:
``(3) For purposes of carrying out this subsection, there
is appropriated, out of any funds in the Treasury not
otherwise appropriated, $995,000,000 for each of fiscal years
2019 through 2021.''.
Page 98, strike line 20 and all that follows through page
99, line 9.
Mr. TONKO (during the reading). Mr. Speaker, I ask unanimous consent
to dispense with the reading.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from New York?
There was no objection.
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from New
York is recognized for 5 minutes in support of his motion.
Mr. TONKO. Mr. Speaker, this is the final amendment to the bill,
which will not kill the bill or send it back to committee. If adopted,
the bill will immediately proceed to final passage, as amended.
For more than a year and a half, Republicans in the House have been
engaged in an all-out ideological assault to weaken healthcare for
Americans by working to repeal the Affordable Care Act and gutting
protections for preexisting conditions. Republicans have repeatedly
voted to strip Medicaid coverage for millions struggling with
addiction. Thanks to Republican policies, we are seeing this uninsured
rate rise sharply for the first time in years.
This attack on our healthcare has had serious consequences for our
ability to adequately address the needs of those struggling with the
opioid epidemic. I remind my friends that we can't have it both ways:
We either are for fighting this epidemic every way we can, or we are
not.
I have seen the carnage this epidemic can produce in my own backyard,
where my hometown of Amsterdam, New York, with a population of a little
over 18,000 people, saw four overdose deaths and a dozen close calls
within a single month.
We know that, as of today, less than 20 percent of Americans who need
substance abuse treatment are able to receive it. We need to move
toward a system of treatment on demand so that, when an individual has
that moment of clarity, we are ready with a helping hand to pull them
away from the deadly grip of addiction.
While I am pleased that the bill before us will make some incremental
progress in our fight against the opioid epidemic and is the product of
a significant amount of bipartisan work, every single Member of this
Chamber knows that we can and we should be doing more. This motion to
recommit is our chance to do just that and to make additional progress
in this fight.
First, the motion would invest in our addiction workforce by
incorporating a proposal advanced by Representatives Crowley and
Costello to add 500 new resident physician slots to hospitals that have
developed or are developing training programs in addiction medicine,
addiction psychiatry, or pain medicine. We all have seen firsthand the
need for more addiction specialists out there, and we have a chance to
take action on that right now.
Secondly, this motion would allot an additional $1 billion annually
to States through 2021 so that we can continue to invest in locally
designed prevention, treatment, and recovery solutions. It is clearly
going to take more than 2 years to battle the epidemic, and we need to
let providers in States know that we are making sustained, meaningful
investments in this area.
Finally, our motion to recommit includes a commonsense prescription
drug policy which will reduce prescription drug prices for all
Americans by reducing gaming by drug manufacturers to prevent generics
from coming to market.
The CREATES Act, introduced by Representatives Marino and Cicilline,
is estimated to save the Federal Government some $3.8 billion and
patients far more. This legislation has been passed by the Senate
Judiciary Committee on a bipartisan basis, but we have been denied a
vote on the House floor to consider this practical, positive policy to
halt pharma gaming and mischief.
Each of the policies contained in this package is bipartisan, fully
paid for, and would bolster our ability to respond to the crisis. We
have the opportunity to provide a more robust response for the American
people and to save the lives of countless of our friends and neighbors
all across this country who could be the next to fall victim to this
deadly disease of addiction.
Every day, every week, every month, every year that passes, the
challenge rests in our collective laps: Will we do more?
We need to do more. Let's do it for those families living with the
pain and loss. Let's do it for those individuals who struggle with the
illness of addiction. Let's be the light, the candle that brightens
their darkness. Let's go forward with the recovery that is inspired by
this legislation.
Mr. Speaker, I urge all of my colleagues on both sides of the aisle
to support this motion to recommit, and I yield back the balance of my
time.
Mr. WALDEN. Mr. Speaker, I claim the time in opposition to the
motion.
The SPEAKER pro tempore. The gentleman from Oregon is recognized for
5 minutes.
Mr. WALDEN. Mr. Speaker, like a lot of our work here that has been
bipartisan, we would hope, going forward, this, too, could become
bipartisan, because we believe that getting prescription drug prices
down is essential. The Trump administration believes that as well and
is doing some things administratively. We are going to be working on
this in the committee.
We also agree that this unmet workforce need is important as well.
Over the course of five hearings, a full markup in subcommittee, two
full markups in the full committee, this issue was never fully brought
and vetted. There is more work to be done here, and we are committed to
doing work on both the CREATES Act and on the Opioid Workforce Act.
As the gentleman from New York, my friend, knows, we have worked out
our differences on many, many issues on this and other topics, and we
intend to move forward. It is just that the agreement we have today,
Mr. Speaker, is about all of us coming together with bills that were
ready for prime time that would not somehow cause problems with the
underlying document.
This proposal, while well-intended and, frankly, on the big scope of
things makes a lot of sense, it is just not ready and agreed to yet.
The gentleman knows that. We know that. We appreciate his passion on
this issue. We share it. But I have to reluctantly oppose the motion to
recommit because we have agreement that only issues we all agree on are
going into this bill--that is, Republicans and Democrats at the top of
both committees.
So I take the signal that he remains committed to this effort to fill
the gap. We will work with him and others going forward because we have
a lot more work to do, Mr. Speaker. This one is just not ready for
prime time.
Mr. Speaker, I urge opposition to the motion to recommit, and I yield
back the balance of my time.
The SPEAKER pro tempore. Without objection, the previous question is
ordered on the motion to recommit.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Mr. TONKO. Mr. Speaker, on that, I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule
XX, this 15-minute vote on the motion to recommit will be followed by
5-minute votes on passage of the bill, if ordered, and agreeing to the
Speaker's approval of the Journal, if ordered.
The vote was taken by electronic device, and there were--yeas 185,
nays 226, not voting 16, as follows:
[Roll No. 287]
YEAS--185
Adams
Aguilar
Barragan
Bass
Beatty
Bera
[[Page H5571]]
Beyer
Bishop (GA)
Blum
Blumenauer
Blunt Rochester
Bonamici
Boyle, Brendan F.
Brady (PA)
Brown (MD)
Brownley (CA)
Bustos
Butterfield
Capuano
Carbajal
Cardenas
Carson (IN)
Cartwright
Castor (FL)
Castro (TX)
Chu, Judy
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Cohen
Connolly
Cooper
Correa
Costa
Courtney
Crist
Cuellar
Cummings
Davis (CA)
Davis, Danny
DeFazio
DeGette
DeLauro
DelBene
Demings
DeSaulnier
Deutch
Dingell
Doggett
Doyle, Michael F.
Engel
Eshoo
Espaillat
Esty (CT)
Evans
Foster
Frankel (FL)
Fudge
Gabbard
Gallego
Garamendi
Gomez
Gonzalez (TX)
Gottheimer
Green, Al
Green, Gene
Grijalva
Gutierrez
Hastings
Heck
Higgins (NY)
Himes
Hoyer
Huffman
Jackson Lee
Jayapal
Jeffries
Johnson (GA)
Johnson, E. B.
Kaptur
Keating
Kelly (IL)
Kennedy
Khanna
Kihuen
Kildee
Kilmer
Kind
Krishnamoorthi
Kuster (NH)
Lamb
Langevin
Larsen (WA)
Larson (CT)
Lawrence
Lawson (FL)
Lee
Levin
Lewis (GA)
Lieu, Ted
Lipinski
Loebsack
Lofgren
Lowenthal
Lowey
Lujan Grisham, M.
Lujan, Ben Ray
Lynch
Maloney, Carolyn B.
Maloney, Sean
Matsui
McCollum
McEachin
McGovern
McNerney
Meeks
Moore
Moulton
Murphy (FL)
Nadler
Napolitano
Neal
Nolan
Norcross
O'Halleran
O'Rourke
Pallone
Panetta
Pascrell
Pelosi
Perlmutter
Peters
Peterson
Pingree
Pocan
Polis
Price (NC)
Quigley
Raskin
Rice (NY)
Richmond
Rosen
Roybal-Allard
Ruiz
Ruppersberger
Rush
Ryan (OH)
Sanchez
Sarbanes
Schakowsky
Schiff
Schneider
Schrader
Scott (VA)
Scott, David
Serrano
Sewell (AL)
Shea-Porter
Sherman
Sinema
Sires
Smith (WA)
Soto
Speier
Suozzi
Swalwell (CA)
Takano
Thompson (CA)
Thompson (MS)
Tonko
Torres
Tsongas
Vargas
Vela
Velazquez
Visclosky
Wasserman Schultz
Waters, Maxine
Watson Coleman
Welch
Wilson (FL)
Yarmuth
NAYS--226
Abraham
Aderholt
Allen
Amash
Amodei
Arrington
Babin
Bacon
Banks (IN)
Barletta
Barr
Barton
Bergman
Biggs
Bilirakis
Bishop (MI)
Bishop (UT)
Blackburn
Bost
Brady (TX)
Brat
Brooks (AL)
Brooks (IN)
Buchanan
Buck
Bucshon
Budd
Burgess
Byrne
Calvert
Carter (GA)
Carter (TX)
Chabot
Cheney
Coffman
Cole
Collins (NY)
Comer
Comstock
Conaway
Cook
Costello (PA)
Cramer
Crawford
Culberson
Curbelo (FL)
Curtis
Davidson
Davis, Rodney
Denham
DeSantis
DesJarlais
Diaz-Balart
Donovan
Duffy
Duncan (SC)
Duncan (TN)
Dunn
Emmer
Estes (KS)
Faso
Ferguson
Fitzpatrick
Fleischmann
Flores
Fortenberry
Foxx
Frelinghuysen
Gaetz
Gallagher
Garrett
Gianforte
Gibbs
Gohmert
Goodlatte
Gosar
Gowdy
Granger
Graves (GA)
Graves (LA)
Graves (MO)
Griffith
Grothman
Guthrie
Handel
Harper
Harris
Hartzler
Hensarling
Herrera Beutler
Hice, Jody B.
Higgins (LA)
Hill
Holding
Hollingsworth
Hudson
Huizenga
Hultgren
Hunter
Hurd
Issa
Jenkins (KS)
Jenkins (WV)
Johnson (LA)
Johnson (OH)
Johnson, Sam
Jones
Jordan
Joyce (OH)
Katko
Kelly (MS)
Kelly (PA)
King (IA)
King (NY)
Kinzinger
Knight
Kustoff (TN)
Labrador
LaHood
LaMalfa
Lamborn
Lance
Latta
Lesko
Lewis (MN)
LoBiondo
Long
Loudermilk
Love
Lucas
Luetkemeyer
MacArthur
Marino
Marshall
Massie
Mast
McCarthy
McCaul
McClintock
McHenry
McKinley
McMorris Rodgers
McSally
Meadows
Messer
Mitchell
Moolenaar
Mooney (WV)
Mullin
Newhouse
Norman
Nunes
Olson
Palazzo
Palmer
Paulsen
Pearce
Perry
Pittenger
Poe (TX)
Poliquin
Posey
Ratcliffe
Reichert
Renacci
Rice (SC)
Roby
Roe (TN)
Rogers (AL)
Rogers (KY)
Rohrabacher
Rooney, Francis
Ros-Lehtinen
Roskam
Ross
Rothfus
Rouzer
Royce (CA)
Russell
Rutherford
Sanford
Scalise
Schweikert
Scott, Austin
Sensenbrenner
Sessions
Shimkus
Shuster
Simpson
Smith (MO)
Smith (NE)
Smith (NJ)
Smith (TX)
Smucker
Stefanik
Stewart
Stivers
Taylor
Tenney
Thompson (PA)
Thornberry
Tipton
Trott
Turner
Upton
Valadao
Wagner
Walberg
Walden
Walker
Walorski
Walters, Mimi
Weber (TX)
Webster (FL)
Wenstrup
Westerman
Williams
Wilson (SC)
Wittman
Womack
Woodall
Yoder
Yoho
Young (AK)
Young (IA)
Zeldin
NOT VOTING--16
Black
Collins (GA)
Crowley
Delaney
Ellison
Hanabusa
Marchant
Meng
Noem
Payne
Reed
Rokita
Rooney, Thomas J.
Titus
Veasey
Walz
{time} 1152
Messrs. DAVIDSON, RUTHERFORD, ROYCE of California, YOUNG of Iowa,
BISHOP of Michigan, McHENRY, BISHOP of Utah, HOLLINGSWORTH, and COLE
changed their vote from ``yea'' to ``nay.''
Ms. SANCHEZ changed her vote from ``nay'' to ``yea.''
So the motion to recommit was rejected.
The result of the vote was announced as above recorded.
The SPEAKER pro tempore. The question is on the passage of the bill.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Mr. WALDEN. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. This is a 5-minute vote.
The vote was taken by electronic device, and there were--yeas 396,
nays 14, not voting 17, as follows:
[Roll No. 288]
YEAS--396
Abraham
Adams
Aderholt
Aguilar
Allen
Amodei
Arrington
Babin
Bacon
Banks (IN)
Barletta
Barr
Barragan
Barton
Bass
Beatty
Bera
Bergman
Beyer
Bilirakis
Bishop (GA)
Bishop (MI)
Bishop (UT)
Blackburn
Blum
Blumenauer
Blunt Rochester
Bonamici
Bost
Boyle, Brendan F.
Brady (PA)
Brady (TX)
Brat
Brooks (IN)
Brown (MD)
Brownley (CA)
Buchanan
Buck
Bucshon
Budd
Burgess
Bustos
Butterfield
Byrne
Calvert
Capuano
Carbajal
Cardenas
Carson (IN)
Carter (GA)
Carter (TX)
Cartwright
Castor (FL)
Castro (TX)
Chabot
Cheney
Chu, Judy
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Coffman
Cohen
Cole
Collins (NY)
Comer
Comstock
Conaway
Connolly
Cook
Cooper
Correa
Costa
Costello (PA)
Courtney
Cramer
Crawford
Crist
Cuellar
Culberson
Cummings
Curbelo (FL)
Curtis
Davidson
Davis (CA)
Davis, Danny
Davis, Rodney
DeFazio
DeGette
DeLauro
DelBene
Demings
Denham
DeSantis
DeSaulnier
DesJarlais
Deutch
Diaz-Balart
Dingell
Doggett
Donovan
Doyle, Michael F.
Duffy
Duncan (SC)
Duncan (TN)
Dunn
Emmer
Engel
Eshoo
Espaillat
Estes (KS)
Esty (CT)
Evans
Faso
Ferguson
Fitzpatrick
Fleischmann
Flores
Fortenberry
Foster
Foxx
Frankel (FL)
Frelinghuysen
Fudge
Gabbard
Gallagher
Gallego
Garamendi
Gianforte
Gibbs
Gomez
Goodlatte
Gottheimer
Gowdy
Granger
Graves (GA)
Graves (LA)
Graves (MO)
Green, Al
Green, Gene
Griffith
Grijalva
Grothman
Guthrie
Gutierrez
Handel
Harper
Harris
Hartzler
Hastings
Heck
Hensarling
Herrera Beutler
Hice, Jody B.
Higgins (LA)
Higgins (NY)
Hill
Himes
Holding
Hollingsworth
Hoyer
Hudson
Huffman
Huizenga
Hultgren
Hunter
Hurd
Issa
Jackson Lee
Jayapal
Jeffries
Jenkins (KS)
Jenkins (WV)
Johnson (GA)
Johnson (LA)
Johnson (OH)
Johnson, E. B.
Johnson, Sam
Jordan
Joyce (OH)
Kaptur
Katko
Keating
Kelly (IL)
Kelly (MS)
Kelly (PA)
Kennedy
Khanna
Kihuen
Kildee
Kilmer
Kind
King (IA)
King (NY)
Kinzinger
Knight
Krishnamoorthi
Kuster (NH)
Kustoff (TN)
LaHood
LaMalfa
Lamb
Lamborn
Lance
Langevin
Larsen (WA)
Larson (CT)
Latta
Lawrence
Lawson (FL)
Lee
Lesko
Levin
Lewis (GA)
Lewis (MN)
Lieu, Ted
Lipinski
LoBiondo
Loebsack
Lofgren
Long
Love
Lowenthal
Lowey
Lucas
Luetkemeyer
Lujan Grisham, M.
Lujan, Ben Ray
Lynch
MacArthur
Maloney, Carolyn B.
Maloney, Sean
Marino
Marshall
Mast
Matsui
McCarthy
McCaul
McCollum
McEachin
McGovern
McHenry
McKinley
McMorris Rodgers
McNerney
McSally
Meadows
Meeks
Messer
Mitchell
Moolenaar
Mooney (WV)
Moore
Moulton
Mullin
Murphy (FL)
Nadler
Napolitano
Neal
Newhouse
Nolan
Norcross
Norman
Nunes
O'Halleran
Olson
Palazzo
Pallone
Palmer
Panetta
Pascrell
Paulsen
Pearce
Pelosi
Perlmutter
Perry
Peters
Peterson
Pingree
Pittenger
Pocan
Poe (TX)
Poliquin
Polis
Posey
Price (NC)
Quigley
Raskin
Ratcliffe
Reichert
Renacci
Rice (NY)
Rice (SC)
Richmond
Roby
Roe (TN)
Rogers (AL)
Rogers (KY)
Rohrabacher
Rooney, Francis
Ros-Lehtinen
Rosen
Roskam
Ross
Rothfus
Rouzer
Roybal-Allard
Royce (CA)
Ruiz
Ruppersberger
Rush
Russell
Rutherford
Ryan (OH)
Sanchez
Sarbanes
Scalise
Schakowsky
Schiff
Schneider
Schrader
Schweikert
Scott (VA)
Scott, Austin
Scott, David
Sensenbrenner
[[Page H5572]]
Serrano
Sessions
Sewell (AL)
Shea-Porter
Sherman
Shimkus
Shuster
Simpson
Sinema
Sires
Smith (MO)
Smith (NE)
Smith (NJ)
Smith (TX)
Smith (WA)
Smucker
Soto
Speier
Stefanik
Stewart
Stivers
Suozzi
Swalwell (CA)
Takano
Taylor
Tenney
Thompson (CA)
Thompson (MS)
Thompson (PA)
Thornberry
Tipton
Tonko
Torres
Trott
Tsongas
Turner
Upton
Valadao
Vargas
Vela
Velazquez
Visclosky
Wagner
Walberg
Walden
Walker
Walorski
Walters, Mimi
Wasserman Schultz
Waters, Maxine
Watson Coleman
Weber (TX)
Webster (FL)
Welch
Wenstrup
Westerman
Williams
Wilson (FL)
Wilson (SC)
Wittman
Womack
Woodall
Yarmuth
Yoder
Yoho
Young (AK)
Young (IA)
Zeldin
NAYS--14
Amash
Biggs
Brooks (AL)
Gaetz
Garrett
Gohmert
Gonzalez (TX)
Gosar
Jones
Labrador
Loudermilk
Massie
McClintock
Sanford
NOT VOTING--17
Black
Collins (GA)
Crowley
Delaney
Ellison
Hanabusa
Marchant
Meng
Noem
O'Rourke
Payne
Reed
Rokita
Rooney, Thomas J.
Titus
Veasey
Walz
{time} 1201
So the bill was passed.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.
____________________